Compass Medical, P.C.
  • Business Office - Professional
  • East Bridgewater, MA, USA
  • Hourly
  • Full Time

Compass Medical offers a complete and competitive benefits package; including Medical, Dental, 401K, PTO, Life and Disability Insurance etc.

Come join our growing Chronic Care Management Team!

Compass medical is looking for Chronic Care Management LPNs to join our emerging department.

Compass Medical is a physician owned and fully integrated healthcare provider that offers high quality healthcare solutions from several locations south of Boston, Massachusetts. Compass Medical is affiliated with Steward Healthcare and offers outstanding patient care.

This is a non-exempt position responsible to provide care coordination services for identified patients eligible for Medicare's Chronic Care Management (CCM) services.  Working closely with the Program Manager, the CCM nurse will provide outreach calls to patients enrolled in our Chronic Care Management Program.  The nurse will be responsible for assessing chronic conditions via phone, medication reconciliation, reviewing and updating care plans under the direction of the physician and coordinating with the care team to help patients meet their goals.   In addition, the nurse will meet regularly with the care team and Program Manager to review care plans for patients and discuss any potential clinical concerns identified.  The nurse will be expected to reach out to all assigned patients monthly and to document all calls in the EHR to ensure compliance with the CCM program.   

This is a full-time position working Monday through Friday.  Candidates must be flexible and available for some 11am to 7pm shifts based on the department needs. Once trained, candidates may have the opportunity to work from home.

Principal Duties and Responsibilities:

  • Demonstrate excellent customer services skills, act as a role model that ensures optimal patient, provider and employee experiences.
  • Provides non face to face assessments of patients with 2 or more chronic conditions and communicates any concerns to the provider and care team as appropriate. 
  • Documents all patient calls in the EHR and upon enrollment creates nursing interventions to help patients meet goals outlined in the provider's care plan. 
  • Provides education to patients with chronic conditions on the importance of medication compliance, diet, exercise etc and ensures patients are following provider instructions for upcoming visits.
  • The CCM nurse will assist in obtaining any outside records from specialists for the Primary Care Physician before upcoming appointments.  The nurse will also make certain the patient is following any recommendations made by specialists. 
  • The CCM nurse will meet regularly with the Program Manager to review case load and identify any work flow issues. 
  • The CCM nurse will be expected to actively communicate with staff nurses, providers and Practice Managers on any and all issues with patients enrolled in the Chronic Care Management Program. 


  • Current Massachusetts licensure as a Licensed Practical Nurse (LPN).
  • Demonstrated understanding of CCM services, coding, and payment
  • 5 years minimum nursing experience preferably with chronically ill patient population.
  • Proficient use of Microsoft Word, Microsoft Excel, patient registries, and web-based tools and the use of an EHR. 

 Skills and Abilities:

  • Demonstrate knowledge of compliant billing protocols, and Medicare CCM service programs
  • HIPAA knowledge and understanding
  • Demonstrated strength in documenting within an EHR
  • Ability to effectively problem-solve when faced with clinical decision making challenges
  • Demonstrate excellent communication skills.
  • Demonstrate ability to work collaboratively and optimally with patients with serious health conditions, as well as with multidisciplinary teams of providers and care givers.
  • Demonstrate a general understanding of managed care principles, goals, and targets


Due to technical issues, we do not recommend that you apply using a mobile device.

Job #01423N

Please, do not contact the department. All recruitment is initially conducted through the Business Office in East Bridgewater. Compass Medical Business Office 362 North Bedford Street Route 18 East Bridgewater, MA 02333  

Compass Medical, P.C.
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