Chronic Care Management

Company: Desert Ridge Family Physicians
Location: Phoenix
Posted on: February 15, 2026

Job Description:

Job Description Job Description Benefits: 401(k) 401(k) matching Competitive salary Health insurance Opportunity for advancement Chronic Care Manager (CCM) Join Our Team - Support Patients, Build Skills, Grow in Care Management Desert Ridge Family Physicians is seeking a Chronic Care Manager (CCM) to support patients with chronic conditions through coordinated, patient-centered care. This role focuses on direct patient management, care coordination, and documentation , while working within established workflows and a collaborative team environment. This is an ideal role for someone who is organized, compassionate, and ready to grow their skills in care management within a structured program. What Youll Do Chronic Care Management Manage a panel of patients enrolled in Chronic Care Management (CCM) and Transitional Care Management (TCM) programs. Conduct patient outreach, follow-ups, and education to support chronic disease management. Assist with medication reconciliation, referrals, and care coordination. Support patients in navigating appointments, labs, imaging, and community resources. Document all care management activities accurately and consistently in the EHR. Provide hybrid care management , including phone based outreach and in office patient support as needed. Care Coordination & Team Collaboration Work closely with physicians, supervisors, and clinical staff to support patient care plans. Follow established CCM and TCM workflows to ensure consistency and compliance. Escalate concerns, barriers, or process improvement ideas through leadership channels. Participate in team meetings and ongoing training. Who You Are Experienced in care coordination, chronic care management, or a similar patient-facing healthcare role. Medical Assistant experience preferred (certification a plus). Organized, dependable, and able to work independently within defined workflows. Comfortable working in a clinic based environment with both patient facing and non patient-facing responsibilities. Strong communicator with patients, caregivers, and internal teams. Open to feedback, coaching, and professional development. Experience with Athena EHR or similar systems preferred. Why Youll Love Working Here Supportive leadership with clear expectations and processes. Structured workflows that allow you to focus on patient care. Opportunities to build skills in CCM, TCM, and care coordination. A collaborative environment that values teamwork and accountability. Meaningful work that helps reduce hospitalizations and improve patient outcomes.

Keywords: Desert Ridge Family Physicians, Tempe , Chronic Care Management, Healthcare , Phoenix, Arizona