Chronic Care Manager

The Chronic Care Manager is a medical assistant who supports the development of patient-centered, team-based care. S/he will support primary care physicians (PCPs) in managing their panel of patients using a population management informatics tool. By gathering and organizing patient data, the Chronic Care Manager works 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 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.Role Description:

Coordinates 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. Interacts with patients using state of the art digital technology and streamlined patient communication tools.

KEY AREAS OF RESPONSIBILITY:

• Develops a keen understanding of primary care practice requirements for optimal, coordinated population health
• Works as an effective team member of the care team
• Works an AI Chronic Care Management platform to support patients with multiple chronic diseases and assists in coordination of the patients care continuum.
• Care plan development using AI and Digital tools to develop a plan of care
• Facilitate the patient’s appropriate condition management and optimize wellness and medical outcomes using AI tool.
• Monitor patient progress toward desired outcomes through AI assessment and evaluation.
• Contributes to quality improvement and care redesign of population health efforts
•  And other duties as assigned

QUALIFICATIONS

• Medical Assistant
• Significant experience within a primary care setting with quality/population health experience in lieu of certification will be considered.