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Chronic Care Manager (CMA, LPN or RN) (FT) | Population Health | Location vary | 2026-101
CHRON004549
Description
GENERAL SUMMARY OF DUTIES: Collaborates with all members of the multidisciplinary healthcare team to ensure the delivery of high quality and cost effective care through provision of care management services to high risk patients in accordance with McFarland Clinic’s Core Values and Promise. SUPERVISION RECEIVED: Reports directly to the Population Health Manager SUPERVISION EXERCISED: None. HIPAA PROTECTED HEALTH INFORMATION (PHI) ACCESS CATEGORY: All—Unlimited access. Performances of such tasks are a condition of employment. TYPICAL PHYSICAL DEMANDS: Requires prolonged sitting, some bending, stooping and stretching. Requires eye-hand coordination and manual dexterity sufficient to operate a keyboard, photocopier, telephone, etc. Occasionally lifts and carries items weighing up to 50 pounds. Requires normal range of hearing and eyesight to record, prepare, and communicate appropriate reports. TYPICAL WORKING CONDITIONS: Work is performed in an office environment. EXAMPLES OF DUTIES: ( This list may not include all the duties assigned.)- For targeted patients, collaborate with the provider and patient/family to evaluate current health status, develop a patient specific care plan to reduce barriers, promote education and self care, secure needed health care and community resources, and avoid inpatient admissions and emergency department visits. Ensure care plan consistency across providers.
- Communicate with targeted patients regularly and counsel on disease related symptom management, address compliance with care plans, and advise patients on lifestyle choices to improve prognosis.
- Proactively connect targeted patients to payor and community health management resources and programs, as patient needs require.
- Verify chronic disease conditions are accurately reflected in the electronic medical record and other disease registries as appropriate.
- Provides education to targeted patients regarding all aspects of his/her care, including medication, tests, procedures, chronic condition specific information etc.
- Proactively identify patients health needs, and works in collaboration with the provider, care navigator, and healthcare team to ensure preventive and /or needed care is arranged.
- Participates in pre-visit planning with the provider and health care team as needed. Order tests/services due prior to office visit.
- Responsible for documentation of all encounters with the patient into the EHR.
- Potential for Remote work after a 90-day period is completed and approval from the manager is given.
- Performs other tasks as assigned by the Population Health Manager in addition to the duties of the Care Manager. These tasks are generally ongoing, require additional knowledge and skills, and reflect a higher level of responsibility.
- Graduation from an accredited program for Medical Assistants
- Graduate of an accredited school of nursing.
- Certification or registration from an approved certifying organization for Medical Assistants (AAMA, ARMA, AMT, NAHP, NCCT, NHA).
- Possession of a State Practical Nurse license.
- Current State of Iowa Registered Nurses license
- Current Basic Life Support certification for Health Care Providers.
- Mandatory Reporting of Dependent Adult and Child Abuse.
- Minimum of 5 years in a multi-specialty clinic or similar organization.
- Experience with population health, care coordination, and/or disease management programs preferred.
- Certified Health Coach preferred.
