Chronic Care ManagerThis is an on-site position at Kidney Care Center of Georgia. The Chronic Care Manager is a CMA or LPN 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 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, 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.Starting pay range for the role: $20/ per hourKEY 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 a Chronic Care Management platform to support patients with multiple chronic diseases and assists in the coordination of the patient's care continuum.
Contributes to quality improvement and care redesign of population health efforts

PRINCIPLE DUTIES AND RESPONSIBILITIES:

Manage patient registries and 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
Contributes 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
Contributes to the teamwork within and between departments. Regularly attends and participates in meetings with coworkers and practice staff.
Perform all job functions in compliance with applicable federal, state, local, and company policies and procedures
And other duties as assigned

QUALITY IMPROVEMENT AND PROCESS DESIGN

Collaborate with care teams to establish population-appropriate, pre-visit, and point-of-care processes
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
Minimum of 2 years of experience in a similar specialty. Experience in population health is preferred
Proven problem-solver with ability to multitask
Prior use of electronic health records and other health care information systems is desirable

QUALIFICATIONS

Certified Medical Assistant or LPN from a nationally recognized organization preferred
Significant experience within a primary care setting with quality/population health experience in lieu of certification will be considered.

*Bilingual English-Spanish would be preferredPI0b7e9f52bdbd-8722-37929033