Job description

Phamily is helping to place a Fully Remote Chronic Care Manager/Chronic Care Navigator for our client, Sweeten Health. This individual will work internally for our client and use the Phamily platform. Phamily is a Chronic Care Management Platform; more information about the Care Management program can be found here: Phamily CCM Platform

The Chronic Care Manager is a 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.

PLEASE READ - 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 multiple chronic disease patients 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
Other duties as assigned

Requirements