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Job Description Summary
The LPN Care Team Member is responsible for conducting Chronic Care Management (CCM) outreach to patients with two or more chronic conditions. This role supports ongoing care coordination, improves patient outcomes, reduces avoidable hospitalizations and emergency department utilization, and promotes patient engagement through structured monthly outreach, education, care plan management and promotes patient well-being through timely follow-up, education, and coordination of services. Entity
MUSC Community Physicians (MCP) Worker Type
Employee Worker Sub-Type
Regular Cost Center
CC005802 MCP - Population Health Transitional Care Management (TCM) Pay Rate Type
Hourly Pay Grade
Health-25 Scheduled Weekly Hours
40 Work Shift
Job Description
Chronic Care Management (CCM)
Key Responsibilities
Conduct monthly telephonic outreach to assigned CCM patient panel
Complete a minimum of 20 minutes of non–face-to-face care management services per patient per calendar month
Perform at least two outreach attempts for patients not reached
Assess patient status, including changes in condition, symptoms, or care needs
Review and reinforce individualized care plans and patient goals
Support medication adherence and identify potential medication concerns
Identify and address barriers to care (e.g., transportation, access to medications, social needs)
Assist with scheduling appointments when clinical evaluation is needed
Escalate clinical concerns to appropriate clinical support staff or providers per workflow standards
Document all interactions accurately in the electronic health record (EHR) and track time for billing compliance
Collaborate with providers, care teams, and community resources to ensure continuity of care
Care Coordination & Patient Engagement
Provide education on chronic disease management and preventive care
Encourage patient participation in primary care and adherence to treatment plans
Monitor for signs of deterioration and escalate concerns appropriately
Support transitions of care when applicable
Promote patient self-management and engagement in their health
Required Skills & Competencies
Strong communication and interpersonal skills
Ability to assess patient needs and apply clinical judgment appropriately
Proficiency in EHR documentation and care coordination workflows (experience with Epic Systems preferred)
Knowledge of chronic disease management and population health principles
Ability to manage a high-volume patient panel efficiently
Strong organizational and time management skills
Ability to work independently within established workflows and SOPs
Ability to appropriately route communication to providers vs. clinical support teams
Qualifications
Active LPN licensure in good standing (South Carolina preferred)
BLS (Basic Life Support) certification (if required by role)
Prior experience in care coordination, case management, ambulatory care, or chronic disease management preferred
Experience working with high-risk or chronic condition populations strongly preferred
Additional Job Description
Benefits:
Health, dental, vision, and life insurance
Employer Sponsored Retirement Plan
Paid time off and extended sick leave
Paid Parental Leave
Disability insurance plan options
Continuous professional and clinical training
Competitive pay
Annual Merit Increase
Wellbeing resources
Tuition Reimbursement
Employee perks and discounts
Employee referral program
Flexible schedule options
Certification incentive program
If you like working with energetic enthusiastic individuals, you will enjoy your career with us!
The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.
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