Medicare Chronic Condition Management Care Coordinator - LVN

Job Title:      Medicare Chronic Condition Management Care Coordinator – LVN

Salary:           $DOE

Location:      Tustin, CA

Openings:    1

Position Purpose:  The Medicare Chronic Condition Management (CCM) Care Coordinator (LVN) is responsible for providing patient-centered care coordination services to Medicare beneficiaries with chronic health conditions. This role ensures patients receive appropriate follow-up, education, and support in managing their health conditions, while meeting regulatory requirements for Medicare Chronic Care Management programs. The LVN will collaborate with physicians, advanced practice providers, and interdisciplinary team members to improve patient outcomes, enhance quality of life, and reduce preventable hospitalizations.  This role will play the point of contact for Medicare patients, navigational series, retention, and liaise with health plans on QI measures, incentive related  RAF scores and STARS.

Core Duties and responsibilities include but are not limited to:

• Serve as the primary point of contact for assigned Medicare patients enrolled in Chronic Condition Management programs.


• Conduct monthly patient outreach calls to review health status, medication adherence, care plan goals, and barriers to care.


• Support the development, implementation, and monitoring of individualized care plans in collaboration with the patient’s primary care provider.


• Provide education to patients and families regarding disease self-management, preventive care, and available resources.


• Coordinate referrals, follow-up appointments, and communication between patients, providers, specialists, and community resources.


• Document all patient interactions, care coordination activities, and updates to the care plan in the electronic health record (EHR) per CMS requirements.


• Monitor patient progress toward goals and escalate concerns to the supervising RN or provider as appropriate.


• Assist with quality initiatives, reporting, and compliance related to Medicare CCM program guidelines.


• Promote patient engagement and adherence to treatment plans to help reduce hospital readmissions and emergency department visits.


• Design activities related to the enhancement of Medicare, older adult activities to help maximize reimbursement and renewals.

This job description in no way states or implies that these are the only duties to be performed by the employee. He or she will be required to follow any other instructions and to perform other duties, within scope, as assigned by his or her supervisor.

Education, Qualifications, and Experience:

• Current and valid California LVN license (or applicable state license).


• Minimum 1–2 years of nursing experience, preferably in primary care, chronic disease management, case management, or care coordination.


• Knowledge of chronic conditions such as diabetes, hypertension, COPD, CHF, and other common Medicare beneficiary diagnoses.


• Familiarity with Medicare Chronic Care Management (CCM) and Transitional Care Management (TCM) requirements strongly preferred.


• Strong patient communication, motivational interviewing, and education skills.


• Proficiency in electronic health records (EHR) and care documentation.


• Ability to work independently, manage multiple priorities, and collaborate effectively within an interdisciplinary team.


• Bilingual (English/Spanish or English/Vietnamese) strongly desired.


• Experience with value-based care or population health management.


• Knowledge of community health resources and social determinants of health.

Families Together of Orange County (FTOC) is proud to be an equal opportunity employer.  FTOC does not discriminate based on race, color, creed, sex, sexual orientation, gender identity or expression, age, religion, national origin, disability, ancestry, marital status, veteran status, medical condition, or any protected category prohibited by local, state or federal laws.