GRACE INTERNAL MEDICINE
Where Our Name Makes the Difference
Care Coordinator — Chronic Care Management (CCM) & Remote Patient Monitoring (RPM)
Open to: Registered Nurse (RN) | Licensed Practical Nurse (LPN) | Experienced Certified Medical Assistant (CMA)
Pay is commensurate with experience and licensure.
POSITION OVERVIEW
Grace Internal Medicine is seeking a dedicated Care Coordinator to support our Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) programs. This role monitors patient data, conducts structured patient outreach, and supports care coordination for patients enrolled in our remote care programs — helping patients stay engaged with their care plans while supporting physicians with proactive monitoring and early identification of clinical concerns.
We are hiring across three tracks — RN, LPN, and experienced CMA — with responsibilities and clinical scope assigned according to license and demonstrated competency. This position works closely with providers and clinical leadership to ensure CCM/RPM services are delivered effectively, compliantly, and with a strong patient experience, consistent with our Patient-Centered Medical Home model.
WHO WE'RE LOOKING FOR
Registered Nurse (RN)
- Active, unencumbered SC RN license Comfortable performing independent nursing assessment, triage, and clinical judgment calls within program protocols Prior experience in chronic disease management, care coordination, or population health preferred
Licensed Practical Nurse (LPN)
- Active, unencumbered SC LPN license Experience with chronic disease monitoring, medication review, and patient education under RN/physician supervision Comfortable following structured clinical protocols and escalation pathways
Experienced Certified Medical Assistant (CMA)
- Current CMA certification (AAMA, NHA, or equivalent) with 2+ years of clinical practice experience Strong track record with patient outreach, data review, and documentation in a clinic setting Works under the direction of the supervising RN/LPN or physician for any activity outside CMA scope of practice
KEY RESPONSIBILITIES
Responsibilities scale with license level. RNs and LPNs may independently perform clinical assessment and escalation within their scope; CMAs support data review, outreach, and documentation and route any clinical judgment call to the supervising nurse or provider.
Patient Enrollment Support
- Identify and contact eligible patients for CCM/RPM enrollment Explain program benefits, expectations, and obtain patient consent Document enrollment accurately in the remote care platform and athenaOne
Patient Monitoring & Engagement
- Review daily patient biometric data, alerts, and readings Monitor adherence to monitoring protocols and follow up on missing or abnormal readings Provide patient education and encouragement around device use and self-management Document all patient interactions in accordance with CMS time and service requirements
Chronic Care Management Outreach
- Conduct monthly CCM care coordination calls Complete medication and care plan reviews (RN/LPN) or support documentation of same (CMA) Identify barriers to care or compliance and communicate them to the care team Log time and services accurately to support billing compliance
CLINICAL ESCALATION
Identify potential clinical concerns and escalate to the supervising provider or nurse per the clinic's established clinical escalation protocol. Examples include:
- Abnormal biometric readings Concerning symptom reports Medication issues Patient safety concerns
RNs and LPNs may perform first-level clinical triage within scope; CMAs escalate all clinical concerns directly to the supervising nurse or provider without independent clinical judgment.
DOCUMENTATION & COMPLIANCE
- Maintain accurate, timely documentation for all CCM/RPM interactions Log patient interaction time in accordance with CMS billing requirements Record clinical and administrative notes in the remote care platform and athenaOne
COLLABORATION WITH PROVIDERS
- Communicate patient concerns and updates to physicians and APPs Assist with care plan adjustments within scope of practice Participate in program improvement discussions and CCM/RPM SOP refinement
PROGRAM IMPACT
This role plays a critical part in helping the practice:
- Improve patient outcomes and chronic disease control Increase proactive, coordinated patient engagement Reduce avoidable hospitalizations and complications Deliver high-quality, compliant CCM and RPM services
SCHEDULE
Monday – Friday, standard clinic hours, with occasional flexibility for patient outreach.
Pay is commensurate with experience and licensure.
ABOUT GRACE INTERNAL MEDICINE
Grace Internal Medicine, LLC (Grace Health) is a Patient-Centered Medical Home in Simpsonville, South Carolina, delivering value-based, relationship-driven primary care. Our mission is reflected in our name — Where Our Name Makes the Difference.
Pay: $24.33 - $29.31 per hour
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Disability insurance
- Employee assistance program
- Health insurance
- Health savings account
- Life insurance
- Paid time off
- Paid training
- Vision insurance
Work Location: Hybrid remote in Simpsonville, SC 29681
