Job Overview
Location
Remote, USA
Job Type
Full-time
Category
Product Management
Date Posted
June 23, 2026
Full Job Description
đź“‹ Description
- • Develop, implement, and monitor care coordination and Chronic Care Management (CCM) workflows and protocols in strict alignment with CMS guidelines.
- • Promote accurate clinical documentation and ensure billing compliance for CCM services to maintain regulatory adherence and revenue integrity.
- • Educate clinical staff on conducting comprehensive patient assessments and maintaining individualized, evidence-based care plans for patients with chronic conditions.
- • Participate in the development, implementation, and monitoring of Transitional Care Management (TCM) program operations to ensure timely post-discharge follow-up and compliance with CMS requirements.
- • Educate clinical teams on coordinating care during transitions from hospital or skilled nursing facilities to home settings to reduce preventable readmissions.
- • Design and implement innovative care models that enhance coordination across inpatient, home health, and community-based care settings.
- • Develop protocols to ensure seamless transitions between levels of care, minimizing gaps and improving patient outcomes.
- • Demonstrate expertise in Accountable Care Organization (ACO) operations and value-based care strategies to align care coordination workflows with population health goals.
- • Serve as the primary point of contact for clinical staff and program leaders on all CCM and care coordination-related inquiries and training needs.
- • Oversee the onboarding and orientation process for new Medical Assistants and care coordinators.
- • Provide ongoing training to clinical team members on best practices in care coordination, documentation, and compliance.
- • Track, report, and analyze key performance indicators (KPIs) to evaluate program effectiveness and identify areas for improvement.
- • Analyze patient outcomes, readmission rates, and utilization data to drive data-informed process enhancements.
- • Implement evidence-based strategies and introduce new technologies or telehealth solutions to optimize care delivery and workflow efficiency.
- • Train staff on new processes, technologies, and compliance updates to foster a culture of continuous improvement and clinical excellence.
🎯 Requirements
- • Active Registered Nurse (RN) license in good standing
- • Proven experience in Chronic Care Management (CCM) and/or Transitional Care Management (TCM) programs
- • In-depth knowledge of CMS guidelines for CCM and TCM billing and documentation
- • Experience educating clinical staff on care coordination protocols and compliance
🏖️ Benefits
- • Full benefits package including medical, dental, and vision coverage
- • 401(k) plan with employer match
- • Generous paid time off (PTO) and paid holidays
- • Professional development opportunities
Skills & Technologies
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About The Pennant Group, Inc.
The Pennant Group is a holding company that oversees a network of independent operating subsidiaries providing home health, hospice, and senior living services across multiple U.S. states. It delivers clinical services such as nursing, therapy, palliative care, and supports assisted living, memory care, and residential senior communities. Each subsidiary retains local management and assets, while Pennant offers centralized support in compliance, technology, finance, and operations. The company was spun off in 2019 and now operates across 13 states.
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