Chronic Care Management Specialist
Summary: The incumbent is a Medical Assistant or LPN who supports the development of patient-
centered, team-based care primarily via text and phone. The goal is to provide assistance for the many
non-face-to-face interactions that are needed to optimally manage multiple chronic conditions.
Although based out of one of our larger clinics, this role will support patients across the practice.
Essential Duties & Responsibilities:
• Support Providers in managing their panel of patients using a population management
informatics tool.
• By gathering and organizing patient data, work to identify patients' unmet needs, engage
patients in their own care using AI and digital tools, gather summary information for treatment
interventions, and enhance ongoing communication between the patient and the care team.
• Facilitate high-value, patient-centered care that improves timely access to and provision of
preventive services and chronic disease treatment.
• Coordinate case management activities relating to chronically ill patients across the continuum
of care including: community resources, consultant referrals, home care, medication adherence,
support biometric health monitoring, and quality gap closure.
• Interact with patients using state of the art digital technology and streamlined patient
communication tools.
• Develop a keen understanding of nephrology practice requirements for optimal, coordinated
population health.
• Works as an effective team member of the care team collaborating with Providers and other
Medical Assistants to address patient requests and inquiries.
• Utilize an AI Chronic Care Management platform to support patients with multiple chronic
diseases, assist in coordination of the patients care continuum, and monitor patient progress
toward desired outcomes through AI assessment and evaluation.
• Facilitate the patient's appropriate condition management and optimize wellness and medical
outcomes using AI tool to create a comprehensive care plan that's specifically focused on the
patients' needs.
• Contribute to quality improvement and care redesign of population health efforts generally for
Medicare but non Medicare patients may also participate.
Education/Experience:
High school diploma or equivalent.
Completion of a medical assistant or LPN program.
3 years of experience in managing/improving health outcomes of patients with comorbidities (i.e.
diabetes, arthritis, hypertension, kidney disease)
Preferred Knowledge, Skills, and Abilities:
Computer savvy and comfortable learning new programs/platforms
Medicare knowledge2
Bilingual (Spanish)
CPR/BLS Certificate.
Phlebotomy experience.
CMA certification.
Experience with EMR (eCW)
Ability to multitask, strong attention to detail, and follow through on tasks.
Strong interpersonal skills with ability to get along with others.
Written and verbal communication skills.
Maintain confidentiality of medical records.
Work with clinical staff and multiple providers.
Relate to the public regardless of racial, ethnic and economic status.
Follow universal precautions to protect self and patients.
Work with high volume in stressful/busy environment.
Physical Strain/work environment:
Work is performed in a busy clinic environment. Frequent contact with employees, patients, providers
and outside agencies. Working under stress and use of telephone required. Manual dexterity required
for use of computer keyboard. Combination of sitting, standing, bending, stooping, and twisting. Must
be able to lift/carry up to 25 pounds. Must have reliable transportation to be able to commute to other
clinic locations to help.
This is In-Person full-time position. Days of work are Monday through Friday; the hours and lunch
period will vary during our open clinic times of 8:00 am to 5:00 pm depending on patient needs.
This job description is not an employment agreement or contract. Management has the exclusive right
to alter this job description at any time without notice. The list of job elements, responsibilities, skills,
duties, requirements, or conditions is not exhaustive, but is merely illustrative of the current
requirements of the essential functions of the job. Reasonable accommodations may be made to enable
individuals with disabilities to perform the essential functions of the job.
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Compensation details: 23-28
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