Chronic Care Navigator

Austin, Texas
Jun 10, 2024
Jun 16, 2024
Work Mode
Work from office
Full Time
Employment Type
Organization Type

P hamily is helping to place a Chronic Care Manager/Chronic Care Navigator for our client in Austin, Texas. This individual will be working internally for our client Austin Pulmonary and using the Phamily platform. Phamily is a Chronic Care Management & Proactive Care Platform and More information about the program can be found here

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 the Phamily platform.

By gathering and organizing patient data, the Chronic Care Navigator 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 treatmen t. Each Care Manager will be expected to manage a 500 patient caseload with 300 billable by the end of month.

Disclaimer: While each role is initially screened by the Phamily team, the ultimate hiring and hiring decisions will be made by the client's hiring team.

  • 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 multiple chronic diseases and assists in coordination of the patients 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 referral to appropriate clinical staff when necessary
  • Recognize and report data inconsistencies to appropriate personnel
  • Contribute to the teamwork within and between departments.
  • 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
  • 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
  • Other duties as assigned

  • Minimum of 3 years experience in relevant specialty. Experience in population health preferred.
  • Proven problem-solver with ability to multitask.
  • Excellent communication skills, both written and spoken.
  • Certified Medical Assistant from a nationally recognized organization. Note: Significant experience within a primary care setting with quality/population health experience in lieu of certification will be considered.

  • Prior use of EHR/EMR systems highly desirable
  • Bi-lingual English-Spanish highly preferred
  • Preference given to candidates who can travel to the client's office for in-person training but proximity is not required.

Powered by JazzHR