Department: Care Management / Primary Care Operations Reports To: Care Management Supervisor, Clinical Manager, or Practice Administrator Company: Ascension Business Solutions LLC Work Setup: Remote (Full-Time) Schedule: U.S. Business Hours (Graveyard Shift, PH Time Role Overview The Chronic Care Management (CCM) Care Coordinator Virtual Assistant supports patients with multiple chronic conditions through structured monthly outreach, medical record review, care plan maintenance, appointment coordination, medication and referral follow-up, and communication with the patient’s healthcare team. This role promotes continuity of care by helping patients follow their provider-approved treatment plans, addressing barriers to care, coordinating outstanding healthcare needs, and ensuring that changes in condition are promptly routed to licensed clinical staff. The CCM Care Coordinator VA does not diagnose conditions, independently interpret test results, prescribe or change treatments, or provide medical advice outside approved protocols. All clinical concerns must be escalated to the appropriate licensed healthcare professional. Key Responsibilities 1. Medical Record and Chart Review * Review provider SOAP notes, medical records, and recent patient activity. * Identify active chronic conditions, documented symptoms, current treatment plans, and provider follow-up instructions. * Review medication lists, refill records, hospitalizations, emergency visits, specialist recommendations, laboratory results, referrals, and outstanding orders. * Identify missed appointments, incomplete testing, unresolved referrals, and overdue follow-up needs. * Note functional, cognitive, behavioral, psychosocial, environmental, and caregiver concerns documented in the record. * Identify discrepancies, abnormal findings, or unclear information requiring clinical review. * Prepare concise, patient-specific chart summaries without copying entire provider notes or carrying forward outdated information. 2. Care Plan Development and Maintenance * Create and maintain comprehensive electronic care plans under the direction of the patient’s clinical team team. * Document each patient’s active conditions, current status, measurable goals, interventions, monitoring needs, barriers, responsible team members, and review dates. * Ensure care plans reflect provider documentation and the patient’s current priorities. * Review care plans during each monthly CCM cycle. * Update care plans following hospitalizations, new diagnoses, medication changes, significant changes in condition, new barriers, or provider instructions. * Track whether goals are new, in progress, achieved, revised, discontinued, or unmet. * Route diagnoses, treatment goals, medication concerns, and monitoring instructions requiring approval to licensed clinical staff. 3. Monthly Patient Outreach * Conduct structured monthly outreach with patients or authorized caregivers using approved workflows. * Review changes in symptoms, function, cognition, mood, appetite, weight, mobility, pain, breathing, falls, and condition-specific concerns. * Review medication adherence, refill needs, reported side effects, recent changes, and medication discrepancies. * Monitor progress toward patient-centered goals and identify new barriers to care. * Reinforce the provider’s existing treatment plan and provide approved educational information. * Confirm patient priorities and involvement in the care plan. * Follow established procedures for patients who cannot be reached. * Avoid documenting a completed patient assessment when meaningful contact did not occur. 4. Care Coordination and Follow-Up * Coordinate appointments, referrals, medical records, transportation, equipment, pharmacy needs, community resources, and communication with outside providers. * Follow up on hospitalizations, emergency visits, rehabilitation stays, specialist recommendations, laboratory tests, imaging, and outstanding orders. * Assist patients with addressing transportation, caregiver, financial, language, technology, or health literacy barriers. * Identify patients requiring routine, priority, post-discharge, or provider follow-up. * Monitor open tasks and follow-up requirements through completion. * Communicate with patients, caregivers, providers, facilities, pharmacies, and internal departments professionally and compassionately. * Escalate high-risk patients who cannot be reached after the required outreach attempts. 5. Clinical Escalation * Recognize symptoms, abnormal findings, medication concerns, or safety issues requiring nurse or provider review. * Immediately escalate urgent or potentially life-threatening concerns according to approved emergency procedures. * Route worsening symptoms, abnormal results, medication discrepancies, and unclear follow-up needs to licensed clinical staff. * Escalate any concern that cannot be safely classified using the approved protocol. * Document the escalation, person notified, instructions received, and follow-up actions. * Keep unresolved clinical issues open until the appropriate disposition has been documented. * Remain within the role’s non-clinical scope at all times. 6. Documentation and Compliance * Document patient-specific care management activities accurately and promptly in the electronic health record. * Record outreach attempts, patient-reported changes, care coordination activities, education provided, care plan updates, escalations, and follow-up tasks. * Track qualifying CCM time according to the client’s approved process. * Ensure documentation clearly reflects the meaningful work completed. * Maintain accurate patient work queues, trackers, and monthly follow-up lists. * Close monthly CCM tasks only after documentation, care plan review, escalation, and follow-up requirements have been completed. * Protect patient information and comply with HIPAA, company, client, and applicable payer requirements. * Participate in training, quality reviews, audits, coaching, and corrective-action activities. Required Qualifications * At least one year of experience in a medical office, primary care practice, care management program, healthcare call center, home health organization, or related healthcare setting. * Experience using an electronic health record and reviewing patient charts. * Familiarity with common chronic conditions, medical terminology, medications, referrals, laboratory reports, and healthcare documentation. * Strong written and verbal English communication skills. * Strong telephone communication and patient-engagement skills. * Excellent attention to detail and documentation accuracy. * Ability to conduct organized, patient-centered conversations using approved workflows. * Ability to identify missing, overdue, inconsistent, or unresolved care needs. * Ability to distinguish routine administrative needs from concerns requiring licensed clinical review. * Strong organizational, time-management, and follow-up skills. * Ability to manage multiple patients, work queues, deadlines, and monthly tasks. * Ability to protect confidential patient information and follow established protocols. * Comfortable working during U.S. business hours or graveyard shifts in the Philippines. * Reliable internet connection and a private, secure remote working environment. Preferred Qualifications * Philippine Registered Nurse or Licensed Nurse. * Nursing graduate or graduate of another allied health or medical program. * Licensed pharmacist, medical technologist, physical therapist, or another related healthcare professional. * Background as a medical assistant, nursing assistant, care coordinator, or health unit coordinator. * Two or more years of experience in chronic care management, primary care, population health, transitional care, or care coordination. * Experience supporting Medicare patients, older adults, or patients with multiple chronic conditions. * Experience developing, maintaining, or updating patient-centered care plans. * Experience conducting patient outreach and documenting care management activities. * Familiarity with CCM documentation and time-tracking requirements. * Experience coordinating with specialists, pharmacies, facilities, home health agencies, caregivers, and community resources. * Experience using electronic health records, patient portals, telephone outreach platforms, and task-management systems. * Familiarity with Homecare Homebase, WellSky, AxisCare, Axxess, AlayaCare, MatrixCare, or similar healthcare platforms. * Knowledge of HIPAA, patient confidentiality, and healthcare documentation requirements. * Previous experience working remotely as a healthcare Virtual Assistant. Training and Performance Expectations * All Virtual Assistants undergo structured onboarding and role-based training. * Client-specific systems, CCM workflows, documentation standards, care plan requirements, and escalation procedures are taught during onboarding. * Ongoing coaching, quality reviews, and performance feedback are part of the role. * Success is measured through timely completion of monthly CCM tasks, documentation quality, care plan accuracy, effective coordination, proper escalation, reliability, and adherence to process. * Care plans must be patient-specific and connect documented conditions to measurable goals and actionable interventions. * Productivity expectations must be met without sacrificing documentation quality, patient safety, or compliance. * Quality and meaningful care management take priority over contact volume alone. Scope and Limitations The CCM Care Coordinator VA works under established client workflows and the supervision of designated clinical or administrative leadership. The coordinator may review records, collect information, conduct approved outreach, update permitted portions of the care plan, coordinate services, and communicate provider-approved instructions. The coordinator may not: * Diagnose medical conditions. * Independently interpret laboratory, imaging, or diagnostic results for patients. * Prescribe, discontinue, or change medications or treatments. * Provide medical advice outside an approved protocol or provider instruction. * Convert a suspected condition into a confirmed diagnosis. * Independently determine that a potentially urgent concern can wait. * Close an unresolved clinical issue without appropriate escalation and disposition. Compensation and Benefits Ascension Business Solutions offers a structured, long-term employment opportunity designed to support stability, growth, and professional development. * Competitive compensation based on experience and role alignment * Paid training and structured onboarding * Fully remote work setup * Company-issued laptop and noise-canceling headset, subject to role and eligibility guidelines * HMO health coverage, subject to company eligibility requirements * Performance-based annual salary increases * Paid Time Off to support work-life balance and well-being * Retention bonus for long-term team members * Referral bonus program * Performance bonuses and incentive programs available upon reaching six months of tenure Why Join Ascension Business Solutions? * You are backed by a company and supported by an established team. * Clear SOPs, documentation standards, and escalation support. * Long-term stability with opportunities for professional growth and role mobility. * Structured training, coaching, and performance management. * A values-driven culture guided by Love, Support, and Excellence. Disclaimer: Responsibilities may evolve based on business needs and client assignments. Employment is at will. How to Apply Complete the Application Form and include the following: * Vocaroo introduction link * Updated resume * Device specifications screenshot * Internet speed test result ⚠️ Incomplete applications may not be processed.