Licensed Practical Nurse-4

Job Description Summary The LPN Care Team Member is responsible for conducting Chronic Care Management (CCM) outreach to patients with two or more chronic conditions. This role supports ongoing care coordination, improves patient outcomes, reduces avoidable hospitalizations and emergency department utilization, and promotes patient engagement through structured monthly outreach, education, care plan management and promotes patient well-being through timely follow-up, education, and coordination of services. Entity MUSC Community Physicians (MCP) Worker Type Employee Worker Sub-Type​ Regular Cost Center CC005802 MCP - Population Health Transitional Care Management (TCM) Pay Rate Type Hourly Pay Grade Health-25 Scheduled Weekly Hours 40 Work Shift Job Description Chronic Care Management (CCM) Key Responsibilities • Conduct monthly telephonic outreach to assigned CCM patient panel • Complete a minimum of 20 minutes of non–face-to-face care management services per patient per calendar month • Perform at least two outreach attempts for patients not reached • Assess patient status, including changes in condition, symptoms, or care needs • Review and reinforce individualized care plans and patient goals • Support medication adherence and identify potential medication concerns • Identify and address barriers to care (e.g., transportation, access to medications, social needs) • Assist with scheduling appointments when clinical evaluation is needed • Escalate clinical concerns to appro