Full Time CCM Nurse



Wilmington, DE, USA
Posted on Wednesday, September 27, 2023
Location: Stoney Batter Family Medicine Associates
Position: Full Time CCM Nurse
Description Summary: Stoney Batter Family Medicine Associate P.A. CCM program provides quality outreach for patients with multiple chronic condition. On a daily basis, CCM Case Manager will coordinate care, outreach to patients providing care management services and accurate and timely documentation.
The duties listed below are the essential functions of this position, and they may change as the needs of the company demand. All CCM Coordinator / Care Managers are expected to do what is necessary to get the work done and to cooperate fully with their supervisor’s requests for additional or altered duties.
Job Type: Full-Time / Part Time
Pay: Based on Credentialling an experience
Health insurance
Paid time off
8-hour shift
Monday to Friday
Flex time available
Ability to commute/relocate or work from home:
Certified Medical Assistant
Licensed Practical Nurse
Certified Registered Nurse

Essential Duties:

  • Identifies and implements the appropriate level of intervention based upon the member’s needs and clinical progress
  • Maintain proper documentation including: Patient notes, Messaging, Care Plans, Medication Reconciliation, Scheduling notes
  • Coordinate with Provider on Goals Patient Needs requirements
  • Shares goals with the member and family as appropriate
  • Schedules follow up calls as necessary
  • Keeps a calendar and f/u on issues If meds were changed
  • BP calls back in a week Depression meds call back in a week
  • Documents progress towards meeting goals and resolving problems
  • Coordinates care and services with other offices as needed
  • Schedule visits
  • Assist provider on AWV’s by completing the assessment portion
  • Orders DME
  • Provide virtual visit to patient when necessary
  • Check voicemails multiple times a day
  • Support other case managers at times of absences including Patient Contact Call coverage Messaging
  • Participate in regularly scheduled meetings as needed
  • Access Aledade APP daily for Admission data on covered patients to avoid readmissions
  • Care Gap
  • Graduates and defers pts when needed
  • Other duties as assigned


  • 1-3 years of experience
  • Strong competency in professional
  • Health Care services industry
  • Must have strong written and verbal skills in English.
  • Experience using Associated software Hospital based systems
  • Must have knowledge of a variety of computer software applications

Skills & Abilities Required:

  • Organized
  • Attention to detail
  • Ability to multitask
  • Strong communication skills
  • Deadline oriented
  • Ability to work with minimal supervision
  • Basic use of Microsoft Produces
  • Ability to work in a team environment
  • Customer service mentality
  • Strong written & verbal communication skills in English
  • Uses critical thinking to assess potential issues and does not focus on just the POC when speaking
  • Be a team player

Physical Requirements:

  • Ability to sit and/or stand for extended periods
  • Ability to perform work on a computer for extended periods
  • Ability to attend work and meetings with excellent attendance and punctuality
  • Ability to bend and lift up to 25 lbs.
  • No travel required
Please note this position is posted on behalf of our partner practices. This individual will be working at the specific practice that is mentioned in the above details and will not be a direct employee of Aledade, Inc. so will therefore not be eligible for the benefits available to Aledade employees.