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Chronic Care Management

Today’s healthcare systems see more patients with multiple chronic illnesses. An expert solution drawing on two decades of clinical support experience maximizes CCM enrollment, increases revenue, and improves health outcomes.

In-Person Support to Increase CCM Enrollment

Our Chronic Care Management navigators work as an extension of your internal staff to enroll and manage CCM patients. From health coaching, routine check-ins, and on-call assistance, we’ll keep patients engaged and proactive throughout their treatment plans. While front office staff may be bogged down with ancillary duties, trained navigators ensure patients connected to the proper local resources, and that lab or other critical needs are met. 

We understand the importance of preventing care gaps, both in terms of revenue and outcomes. By regularly scanning files for changes and improvements in the care setting or at home, our navigators update documentation and correct chart inaccuracies. Unaccounted Medicare codes, such as CPT 99490, can be costing you millions in lost federal funds. Our Care Navigators are specially trained in Medicare coding and embedded into your CareTeam to ensure accurate capture and documentation of services that your team is already performing. Let us maximize your CCM program to increase revenue, while also strengthening patient outreach beyond the care setting to improve overall health outcomes.

The ScribeAmerica Approach

ScribeAmerica embeds in your practice, working elbow-to-elbow with providers so that patients keep appointments, have assistance with transportation, and receive immediate care if necessary.


Population health management

We help control costs while improving population outcomes through our analytics, care management and more.


Top-of-license efficiency

Our navigators function seamlessly within your practice to enable providers to work on tasks ideally suited for their clinical expertise.


Developing customized care plans

Navigators connect with patients to schedule appointments, monitor adherence, and even identify at-risk patients for customized care.


Connecting to local resources and facilities

Tracking down the right local resources requires time that overworked providers seldom have. Our navigators can connect patients to the appropriate accessible facilities.


Ensuring labs and other critical needs are met

Routine check-ins and on-call assistance closes the care gap where labs and other needs are concerned.


Ongoing assistance to help self-manage conditions

We empower patients to achieve their health goals by coaching them on better nutrition and compliance with exercise or other related plans.


Higher reimbursement rates

Our navigators are experts on CMS documentation guidelines that can yield greater revenue.

How it Works

Don’t let patients slip through the care gaps. We connect technology and care coordination tactics to proactively reach at-risk patients. Both on-site in the care setting or at home, Navigators connect with patients to schedule appointments, monitor adherence and so much more. Get access to critical information in less time, while navigators partner with patients to manage their care.

Navigators are embedded into your practice

  • Working elbow-to-elbow with your care team
  • Freeing providers to work top-of-license

Let the Navigators connect with your patients

  • Successfully enroll high numbers of patients
  • Expand your CCM program with minimum investment

Navigators coordinate to empower patients

  • Keep a watchful eye on changes and improvements
  • Constantly updating charts to correct inaccuracies
  • Empower patients to keep appointments, organize transportation, and receive immediate care if necessary

Our nationwide population is aging, which means Chronic Care Management is an important opportunity to benefit patients as well as providers engaged in the shift to value. It is a better use of your resources to partner outside your system with expert navigators trained to enroll a higher numbers of patients and expand your CCM program.

Our team has clinical support experience and a valuable understanding of those living with two or more chronic conditions. Navigators accurately document and monitor customized care plans, which streamlines revenue management and improves patients’ lives.