Chronic Care Manager (Internal Candidates Only)

The Chronic Care Manager is a medical assistant who supports the development of patient-centered, team-based care. This role will support our nephrologists and advanced practice providers in managing their panel of patients using the Phamily platform. Phamily is a Chronic Care Management & Proactive Care Platform. More information about the program can be found here https://phamily.com/ccm-solution/

By gathering and organizing patient data, the Chronic Care Manager works to identify patients’ unmet needs, engage patients in their own care, gather summary information for treatment interventions, and enhance ongoing communication between the patient and her/his care team. The goal of the Chronic Care Management program is to facilitate high-value, patient-centered care that improves timely access to and provision of preventive services and chronic disease treatment. Each Care Manager will be expected to manage a 500 patient caseload with 300 billable by the end of month.

Chronic Care Navigator KEY AREAS OF RESPONSIBILITY:

• Develop a keen understanding of nephrology practice requirements for optimal, coordinated population health
• Work as an effective team member of the care team

• Collaborate with care teams to establish population-appropriate, pre-visit, and point of care processes
• Work with the Phamily Chronic Care Management platform to support patients with multiple chronic diseases and assists in coordination of the patients care continuum.
• Contribute to quality improvement and care redesign of population health efforts
• Manage patient registries 
• Provide the members of health care teams in designated practices with the data required to meet the health needs of the patient
• Support practice staff to develop interventions to proactively manage target populations
• Contribute to a positive experience for patients and families through courteous telephone and digital interactions, accurate and expeditious routing, as well as referral to appropriate clinical staff when necessary
• Recognize and report data inconsistencies to appropriate personnel
• Contribute to the teamwork within and between departments. 
• Regularly attend and participate in meetings with coworkers and practice staff.
• Perform all job functions in compliance with applicable federal, state, local and company policies and procedures
• Provide data to the care teams to properly perform these processes
• Monitor and correct patient attribution to the practice and the care teams within the practice
• Other duties as assigned

REQUIRED QUALIFICATIONS

• Minimum of 3 years experience in nephrology.
• Proven problem-solver with ability to multitask.
• Excellent communication skills, both written and spoken. 
• Trained Medical Assistant from a nationally recognized organization. Note: Significant experience within a primary care/nephrology setting with quality/population health experience  will be considered.

PREFERRED QUALIFICATIONS

• Prior use of EHR/EMR systems highly desirable
• Population Health experience
• Bi-lingual English-Hmong, English-Spanish, English-Somali

Salary : $22 - $26