LPN or CMA - Chronic Care Manager
Company: Phamily
Location: Gainesville
Posted on: July 2, 2025
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Job Description:
Job Description Chronic Care Manager This 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 hour 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 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 preferred PI3bab9e6935c5-25405-37929033
Keywords: Phamily, Athens , LPN or CMA - Chronic Care Manager, Healthcare , Gainesville, Georgia
