Chronic Care Manager - Jaan Health, Inc.

Phamily is helping to place a Chronic Care Manager/Chronic Care Navigator for our client in Mountain Home, AR. This individual will be working internally for our client, Lincoln Paden Medical Group, and using the Phamily platform. Phamily is a Chronic Care Management Platform; more information about the Care Management program can be found here: https://phamily.com/ccm-solution/

The Chronic Care Manager is a Medical Assistant or Licensed Practical Nurse who supports the development of patient-centered, team-based care. S/he will support primary care physicians (PCPs) and practices in managing their panel of chronic care patients using the Phamily platform.

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. 

Disclaimer: While each candidate is initially screened by a Phamily Recruiter, hiring decisions will ultimately be made by the client’s hiring team.

Areas of Responsibility

• Develop a keen understanding of primary care 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 chronic disease and assists in coordination of the patient’s 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 referrals to appropriate clinical staff when necessary
• Recognize and report data inconsistencies to appropriate personnel
• 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
• Monitor and correct patient attribution to the practice and the care teams within the practice
• Other duties as assigned

Requirements

• Minimum of 1 year experience as a Certified Medical Assistant or Licensed Practical Nurse.. Experience in population health preferred.
• Proven problem-solver with ability to multitask.
• Excellent communication skills, both written and spoken.

Preferred Qualifications

• Prior use of EHR/EMR systems highly desirable
• Experience in Internal Medicine
• Prior experience with Care or Case Management

Benefits

Full-time; 8:00 AM - 5:00 PM, Monday-Friday.