chronic care manager

Healthy Home Primary Care

About Us:Healthy Home Primary Care is dedicated to providing high-quality, compassionate care to our patients, primarily an elderly population. We are a patient-centered practice that values teamwork and strives to make a meaningful impact in the lives of those we serve.Job Summary:At Healthy Home Primary Care, we are looking for a dedicated and personable Licensed Practical Nurse (LPN) who will lead our CCM programs that focuses on patients who have multiple (two or more) chronic conditions that are expected to last at least 12 months or more. We provide an essential service that helps providers stay in touch with and meet their patients&rsquo; healthcare needs in between office visits.The role of an LPN Personal Care Coordinator is to care for patients in our program while working in conjunction with the patient&rsquo;s care team to facilitate and address existing and new chronic health issues through outbound phone calls. This position also focuses on assisting patients in obtaining the resources they need to improve their health, happiness, and longevity.We are looking for nurses who are passionate patient advocates who want to form ongoing, collaborative relationships with their patients to improve their lifestyles for the better.Key Responsibilities:<ul><li>Conduct thorough patient assessments to develop individualized care plans that address complex chronic conditions.</li><li>Provide ongoing patient education on disease management, medication adherence, lifestyle modifications, and self-care techniques.</li><li>Coordinate with physicians, specialists, and community resources to ensure seamless delivery of care and appropriate follow-up.</li><li>Utilize electronic health record (EHR) systems such as Intergy to document patient interactions accurately and efficiently.</li><li>Monitor patient progress through regular check-ins via phone calls or telehealth platforms, adjusting care plans as needed.</li><li>Assist with medication management, including administration of injections and IV infusions when appropriate.</li><li>Support patients with comorbidities such as diabetes, hypertension, cardiac issues, or respiratory conditions by providing targeted interventions.</li><li>Ensure compliance with HIPAA regulations and maintain meticulous medical documentation to uphold confidentiality and legal standards.</li></ul>Other Responsibilities<ul><li>Patient Intake: Room patients, reconcile medications, collect medical history, take vitals, and complete screening questionnaires.</li><li>Care Coordination: Triage phone calls and collaborate with providers to ensure patients receive appropriate and timely care.</li><li>Patient Follow-Up: Call patients to address clinical concerns, provide lab/imaging results, and offer continued support.</li><li>Transitional Care Coordination: Monitor hospitalization records, request records, and set up appointments as necessary.</li><li>Phlebotomy &amp; Specimen Processing: Perform blood draws, draft lab orders, and process specimens.</li><li>Provider Support: Assist providers with medication refills, imaging orders, and other tasks as directed.</li><li>Pre-Operative Coordination: Ensure pre-op clearance by ordering necessary labs and imaging.</li><li>Preventative Care: Close HEDIS care gaps by coordinating preventative medicine and care plans with patients.</li><li>Point-of-Care Testing &amp; Procedures: Perform injections (subcutaneous/intramuscular), nebulizer treatments, and other point-of-care testing as directed by the provider.</li></ul>Requirements<ul><li>Valid nursing license with current registration in the relevant state or region.</li><li>Proven experience in chronic disease management within settings such as primary care, long-term care facilities, or home health environments. (preferred)</li><li>Familiarity with EMR/EHR systems for documentation and case tracking.</li><li>Strong clinical skills including vital signs assessment, medication administration, aseptic technique, and wound care.</li><li>Knowledge of ICD-10 coding standards for accurate documentation and billing purposes.</li><li>Experience working with diverse populations including elderly patients in assisted living or nursing homes.</li><li>Ability to perform comprehensive patient assessments and triage effectively in fast-paced environments.</li><li>Excellent communication skills to educate patients and collaborate effectively with multidisciplinary teams across the practice and local healthcare facilities.</li></ul>Skills &amp; Abilities:<ul><li>Personable and compassionate with a strong desire to work with an elderly population.</li><li>Excellent communication skills with the ability to engage patients in a warm, respectful manner.</li><li>Strong problem-solving skills and ability to work independently and as part of a team.</li><li>Dependable and trustworthy with a commitment to showing up every day and ensuring the job gets done.</li><li>Strong organizational skills and ability to multi-task in a fast-paced environment.</li><li>Familiarity with HIPAA regulations and maintaining patient confidentiality.</li></ul>Work Hours:Monday through Friday, 8 a.m. &ndash; 5:30 p.m.Normal hours are 40/week.This job description is intended to convey information essential to understanding the scope of the position and is not an exhaustive list of skills, efforts, duties, responsibilities, or working conditions associated with it.Pay: $26.00 - $30.00 per hourBenefits:<ul><li>Paid time off</li></ul>Work Location: In person

Chronic Care LPN

Ennoble Care

<div><div>About Us

Ennoble Care is a mobile primary care, palliative care, and hospice service provider with patients in New York, New Jersey, Maryland, DC, Virginia, Oklahoma, Kansas, Pennsylvania, and Georgia. Ennoble Care's clinicians go to the home of the patient, providing continuum of care for those with chronic conditions and limited mobility. Ennoble Care offers a variety of programs including, remote patient monitoring, behavioral health management, and chronic care management, to ensure that our patients receive the highest quality of care by a team they know and trust. We seek individuals who are driven to make a difference and embody our motto, &quot;To Care is an Honor.&quot; Join Ennoble Care today!</div>
Purpose:

We are looking for an experienced Advanced Practice Provider (Nurse Practitioner or Physician Assistant) to provide palliative care to patients in home-based settings in the Philadelphia, PA region on a full-time basis. You will apply medical techniques and principles under the supervision of a physician, and you will care for a diverse set of patients with chronic diseases.

What You'll Do:
<ul>
<li>Provide high quality care to palliative patients in and around Philadelphia, PA.</li>
<li>Assess patients' health by performing physical examinations; obtaining, updating, and studying medical histories and creating the best plan for care.</li>
<li>Effectively communicate with office staff and clinical operations across various internal platforms</li>
<li>Provide high quality, patient centered care to a panel of patients</li>
<li>Collaborate with patients' entire care team to provide palliative care recommendations and develop holistic, interdisciplinary plans of care</li>
<li>Foster trust and consult with patients, families, and caregivers during visits</li>
<li>Lead sensitive conversations with patients and families regarding goals of care, advance care planning and the transition to hospice care</li>
<li>Order diagnostic testing as medically necessary</li>
<li>Prescribe medications supplies and appropriate medically necessary interventions</li>
</ul>
What You'll Need:
<ul>
<li>Board Certified, with a valid NP or PA certification in the state of Pennsylvania</li>
<li>Strong clinical skills with the ability to accurately and confidently treat, assess, and diagnose</li>
<li>Positive demeanor and strong people skills</li>
<li>Ability to confidently solve problems and operate independently</li>
<li>2-3 years of palliative, chronic care management or primary care experience with geriatric patients (hospice experience is highly preferred but not required)</li></ul> 


What you'll get:
<ul>
<li>A flexible schedule - so you can see your patients during a schedule that works for you</li>
<li>Autonomy - so you can feel trusted to provide the best care possible.</li>
<li>Support - from our in-house clinical team with any requests or orders.</li>
<li>Growth - the opportunity to join our growing leadership team</li>
</ul>
Compensation:
<ul>
<li>$120-150k+ (depending on experience and other incentives)</li>
</ul>
#tan<div>
Full-time employees qualify for the following benefits:
<ul>
<li>Medical, Dental, Vision and supplementary benefits such as Life Insurance, Short Term and Long Term Disability, Flexible Spending Accounts for Medical and Dependent Care, Accident, Critical Illness, and Hospital Indemnity.</li>
<li>Paid Time Off</li>
<li>Paid Office Holidays</li>
</ul>
All employees qualify for these benefits:
<ul>
<li>Paid Sick Time</li>
<li>401(k) with up to 3% company match</li>
<li>Referral Program</li>
<li>Payactiv: pay-on-demand. Cash out earned money when and where you need it!</li>
</ul>
Candidates must disclose any current or future need for employment-based immigration sponsorship (including, but not limited to, OPT, STEM OPT, or visa sponsorship) before an offer of employment is extended.

Ennoble Care is an Equal Opportunity Employer, committed to hiring the best team possible, and does not discriminate against protected characteristics including but not limited to - race, age, sexual orientation, gender identity and expression, national origin, religion, disability, and veteran status.</div></div>

Complex Care Nurse Practitioner/Physician Assistant (North Philadelphia)

One Medical

<div><div><div>About Us
</div>
<div>One Medical is a primary care solution challenging the industry status quo by making quality care more affordable, accessible and enjoyable. But this isn't your average doctor's office. We're on a mission to transform healthcare, which means improving the experience for everyone involved - from patients and providers to employers and health networks. Our seamless in-office and 24/7 virtual care services, on-site labs, and programs for preventive care, chronic care management, common illnesses and mental health concerns have been delighting people for the past fifteen years.

In February 2023 we marked a milestone when One Medical joined Amazon. Together, we look to deliver exceptional health care to more consumers, employers, care team members, and health networks to achieve better health outcomes. As we continue to grow and seek to impact more lives, we're building a diverse, driven and empathetic team, while working hard to cultivate an environment where everyone can thrive.
</div></div>
Program Overview

The Advanced Care Partner Program creates a team-care structure to collaborate with PCPs who are managing complex patient panels.

The ACP &quot;care team&quot; model pairs a highly clinically experienced provider (ACP) with a PCP to collaborate closely by sharing the care and continuity management of the patient panel. The PCP's task queue provides the focus of this collaborative platform whereby the Advanced Care Partner devotes their work to keeping all categories within SLAs, provides real time responses to patient messages, follows up with chronic care monitoring and management, and intimately understands the patient panel &quot;as their own&quot;, such that complex patients are known well, medical issues are managed efficiently, highest quality conversations engage patients' trust, and continuity of care between the patient and two providers is seamless and exemplary. Further, the ACP care-team model promotes career-sustainability, mitigates the potential for decision fatigue, prevents practice isolation, and addresses burn-out risk factors. The program prioritizes well-being and belonging for both patients and PCPs.

Advanced Care Partner Role:

The Advanced Care Partner is a full-time, remote clinician who works business hours live online with a team of PCP peers, a clinical supervisor, and the Clinical Case Management team of Care Navigators and nurses, as needed, for highly complex cases. The ACP will partner with approximately 5 PCPs and their patient panels, owning these shared panels with longitudinal accountability over time.

The ACP is responsible for maintaining task category SLAs, including but not limited to:
<ul>
<li>Answering clinical questions from patients and engaging in clinical dialogue to complete these conversations.</li>
<li>Clinical decision-making resulting from information coming from messages, lab results, and consults.</li>
<li>Owning medication changes, titrations, and adjustments for chronic conditions as needed.</li>
<li>Providing video visits and phone follow-up care as needed.</li>
<li>Completing clinical paperwork such as disability, FMLA, home health sign-offs.</li>
<li>Attention to closing patient care gaps, creating orders and follow up as needed</li>
<li>Processing Consults and providing related follow up management/care as needed.</li>
<li>Referrals to and collaboration with Clinical Case Management.</li>
<li>Providing urgent visit patient scheduling as needed.</li>
<li>Providing continuity of care longitudinally.</li>
<li>Participating as an active member of the care team including real-time Slack room responses, attending huddles, presenting cases, providing support to CCM team members.</li>
</ul>
Employment type:

<ul><li>40 hours per week. Business hours schedule; must be able to work in two time zones</li>
<li>Occasional weekend/holiday coverage required</li>
<li>Remote live video/phone/slack</li>
<li>Reports to the Medical Director, Advanced Care Partner Program</li>
</ul>
Your Qualifications:
<ul>
<li>5+ years experience as an FNP/PA</li>
<li>Remote/virtual medical care deep practice experience and proficiency</li>
<li>Experience: chronic disease care management, metabolic disease expertise, patient education skills, CGM and EKG data analysis</li>
<li>Strength: expertise in managing high risk patient caseload</li>
<li>Must be currently licensed in CA</li>
</ul>
You'll be set up for success if you have:
<ul>
<li>Excellent communication and interpersonal skills working collaboratively with colleagues</li>
<li>Comfortable and enthusiastic to participate in a team-based care model</li>
<li>Practicing at top of scope; challenging the status quo</li>
<li>Compassionate, culturally-competent motivational style when communicating with patients and skill in navigating difficult conversations</li>
<li>Must be a disciplined self-starter- able to work enthusiastically, creatively, autonomously and efficiently</li>
<li>Prior professional experience working with complex patient populations such as terminally ill, unstable co-morbidities, chronic conditions risk reduction</li>
<li>High Proficiency of technology, keyboarding and data platforms to deliver high quality care</li>
<li>Welcome openness to feedback and reflection to gain productive insight into strengths and growth areas of medical practice and teamwork</li>
<li>The ability to confidently problem-solve, manage and own &quot;outside the box&quot; situations with both patients and colleagues</li></ul> 


This is a full-time virtual role.

One Medical is committed to fair and equitable compensation practices.

The base hourly range for this role is $61.00 to $67.50 per hour based on a full-time schedule. Final determination of starting pay may vary based on factors such as practice experience and patient care schedule. For more information, visit https://www.onemedical.com/careers/.<div> 
One Medical offers a robust benefits package designed to aid your health and wellness. All regular team members working 24+ hours per week and their dependents are eligible for benefits starting on the team member's date of hire:

Taking care of you today
<ul>
<li>Paid sabbatical for every five years of service</li>
<li>Free One Medical memberships for yourself, your friends and family</li>
<li>Employee Assistance Program - Free confidential services for team members who need help with stress, anxiety, financial planning, and legal issues</li>
<li>Competitive Medical, Dental and Vision plans</li>
<li>Pre-Tax commuter benefits</li>
<li>PTO cash outs - Option to cash out up to 40 accrued hours per year</li>
</ul>
Protecting your future for you and your family
<ul>
<li>401K match</li>
<li>Credit towards emergency childcare</li>
<li>Company paid maternity and paternity leave</li>
<li>Paid Life Insurance - One Medical pays 100% of the cost of Basic Life Insurance</li>
<li>Disability insurance - One Medical pays 100% of the cost of Short Term and Long Term Disability Insurance</li>
</ul>
In addition to the comprehensive benefits package outlined above, practicing clinicians also receive
<ul>
<li>Malpractice Insurance - Malpractice fees to insure your practice at One Medical is covered 100%.</li>
<li>UpToDate Subscription - An evidence-based clinical research tool</li>
<li>Continuing Medical Education (CME) - Receive an annual stipend for continuing medical education</li>
<li>Rounds - Providers end patient care one hour early each week to participate in this shared learning experience</li>
<li>Discounted rate to attend One Medical's Annual REAL primary care conference</li>
</ul>
One Medical is an equal opportunity employer, and we encourage qualified applicants of every background, ability, and life experience to contact us about appropriate employment opportunities. 
 
One Medical participates in E-Verify and will provide the federal government with your Form I-9 information to confirm that you are authorized to work in the U.S. Please refer to the E-Verification Poster and Right to Work Poster for additional information.</div></div>

Nurse Practitioner OR Physician Assistant - Advanced Care Partner - CA license - Remote

Arcare

<div>Job Title: Assistant Director of Remote Care Management 
Job Type: Full-time (Monday-Friday, 8:00 AM - 5:00 PM) 
Travel: 40-60%

Qualifications:
<ul><li>
RN license in the appropriate state preferred</li><li>
At least two years of experience in nursing. Management experience preferred.</li><li>
Proficiency in Microsoft Office and the ability to learn and utilize electronic health record (EHR) systems</li><li>
Current CPR and TB certification (required at hire date and annually thereafter)</li><li>
Strong organizational, communication, and interpersonal skills</li></ul>

Job Summary: 
Discover a rewarding career at Arcare. We are seeking a dedicated and patient-focused Assistant Director of Remote Care Management provides support and oversight for planning, implementation and evaluation of the Coordinated Care Remote Care services, including but not limited to: Chronic Care Management (CCM), Remote Patient Monitoring (RPM), and Transitions of Care Management (TCM). The Assistant Director of Remote Care Management will support the Director of Remote Care Management as a liaison for the selected vendor/platforms for CCM and RPM services and equipment. The Assistant Director of Remote Care Management is responsible for attending, scheduling and leading team meetings with a quality improvement focus.

Skills &amp; Attributes
<ul><li>
Strong communication and relationship-building skills, with the ability to work with diverse populations</li><li>
Knowledge of chronic disease management and local healthcare resources</li><li>
Ability to adapt to changing environments and technologies</li><li>
Detail-oriented with strong organizational and time-management skills</li><li>
Ability to work independently and collaboratively as part of a care team</li></ul>

Company Paid Benefits:
<ul><li>
Health, dental, and vision insurance</li><li>
Paid time off (sick and vacation, up to 96 hours accrued annually)</li><li>
Eight (8) paid holidays</li><li>
One (1) floating holiday</li><li>
One (1) birthday holiday</li><li>
Life insurance</li><li>
Long-term disability</li><li>
Free Arcare clinic benefits for employees with Arcare health insurance</li><li>
Retirement plan (401(k) with company matching up to 200% of 4% after 1 year of employment)</li><li>
Additional supplemental and family coverage available</li></ul>

Application Assistance: 
If you need assistance with the application process, please email humanresources@arcare.net.

Equal Opportunity Employer: 
Arcare is committed to creating a diverse environment and is proud to be an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other characteristic protected by law.

#ind3</div>

Assistant Director of Remote Care Management

<div>Job Title: Chronic Disease Case Manager LPN 
Job Type: Full-time (Monday-Friday, 8:00 AM - 5:00 PM) 
Travel: 0-15%

Qualifications:
<ul><li>
Associate&rsquo;s Degree in a related field required; LPN license in the appropriate state preferred</li><li>
At least one year of experience in a medical facility, with a background in case management or chronic disease care preferred</li><li>
Proficiency in Microsoft Office and the ability to learn and utilize electronic health record (EHR) systems</li><li>
Current CPR and TB certification (required at hire date and annually thereafter)</li><li>
Strong organizational, communication, and interpersonal skills</li></ul>

Job Summary: 
Discover a rewarding career at Arcare. We are seeking a dedicated and patient-focused Chronic Disease Case Manager LPN to join the Arcare team. In this role, you will provide education and case management support to patients living with chronic diseases, including those with HIV. You will work closely with healthcare providers, care teams, and external organizations to ensure patients receive the support they need to manage their health effectively.

Responsibilities include coordinating chronic care services, providing health education, monitoring patient progress, and assisting with referrals. The ideal candidate will possess excellent communication skills, a strong understanding of chronic disease management, and the ability to build meaningful relationships with patients and their care teams. This role combines hands-on support with administrative duties to improve patient outcomes and promote overall well-being.

Key Responsibilities:
<ul><li>
Develop individualized care plans for patients enrolled in chronic disease management programs.</li><li>
Monitor and update care plans regularly based on patient needs and acuity levels.</li><li>
Provide health education on disease prevention, management, and healthy lifestyle habits.</li><li>
Assist patients with navigating healthcare systems, including scheduling appointments and accessing resources.</li><li>
Conduct regular follow-ups with patients via phone, telehealth, or in-person visits.</li><li>
Collaborate with healthcare providers to coordinate care and case conferences.</li><li>
Maintain accurate and timely documentation in electronic health records (EHR) and other required systems.</li><li>
Advocate for patients by connecting them to community resources and support services.</li><li>
Provide education about medication adherence, disease management, and risk reduction.</li><li>
Participate in outreach events and community activities as directed.</li><li>
Ensure compliance with all federal, state, and local regulations related to care delivery.</li></ul>

Skills &amp; Attributes
<ul><li>
Strong communication and relationship-building skills, with the ability to work with diverse populations</li><li>
Knowledge of chronic disease management and local healthcare resources</li><li>
Ability to adapt to changing environments and technologies</li><li>
Detail-oriented with strong organizational and time-management skills</li><li>
Ability to work independently and collaboratively as part of a care team</li></ul>

Company Paid Benefits:
<ul><li>
Health, dental, and vision insurance</li><li>
Paid time off (sick and vacation, up to 96 hours accrued annually)</li><li>
Eight (8) paid holidays</li><li>
One (1) floating holiday</li><li>
One (1) birthday holiday</li><li>
Life insurance</li><li>
Long-term disability</li><li>
Free Arcare clinic benefits for employees with Arcare health insurance</li><li>
Retirement plan (401(k) with company matching up to 200% of 4% after 1 year of employment)</li><li>
Additional supplemental and family coverage available</li></ul>

Application Assistance: 
If you need assistance with the application process, please email humanresources@arcare.net.

Equal Opportunity Employer: 
Arcare is committed to creating a diverse environment and is proud to be an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other characteristic protected by law.

#IND2</div>

Chronic Disease Care Management Nurse- LPN

Associate Property Manager

Alex Y. Hernandez MD Inc

Job Overview:We are seeking a dynamic and compassionate Bilingual Family Medicine Nurse Practitioner to join our dedicated healthcare team. In this vital role, you will provide comprehensive primary care services to diverse patient populations, including children, adults, seniors, and individuals with special needs. Your expertise will help promote health, manage chronic conditions, and deliver exceptional patient-centered care across various clinical settings. Fluency in both English and Spanish is essential to effectively communicate with our diverse community. This position offers an exciting opportunity to make a meaningful impact while working in a fast-paced, supportive environment committed to excellence in healthcare delivery.Duties:<ul><li>Conduct thorough patient assessments, including vital signs, physical examinations, and medical histories across pediatric, adult, and geriatric populations.</li><li>Develop and implement individualized care plans that encompass disease prevention, health promotion, and management of acute and chronic conditions.</li><li>Administer injections, as well as perform procedures such as suturing, joint injections, ingrown toe nails and cyst removal using sterile techniques.</li><li>Utilize electronic health record (EHR) systems like NextGen to document patient encounters accurately and efficiently while ensuring compliance with HIPAA regulations.</li><li>Provide triage services and subsequent appointments via telehealth or in-person to assess and treat urgent needs and coordinate appropriate care pathways.</li><li>Manage complex cases involving behavioral health issues, chronic disease, geriatrics, or infectious disease care.</li><li>Collaborate with referrals to specialists for comprehensive patient management.</li><li>Educate patients on medication administration, nutrition, lifestyle modifications, and disease prevention strategies while supporting family planning and long term health care planning efforts.</li><li>Valid Nurse Practitioner license with current certification to practice independently in the state of California.</li><li>Bilingual proficiency in English and Spanish- a must; experience working with diverse populations is highly preferred.</li><li>Demonstrated experience in outpatient primary care settings or urgent care/emergency room. ​</li><li>Strong background in managing acute on chronic diseases, ICU experience, hospital medicine or medical-surgical units is advantageous.</li><li>Familiarity with EMR/EHR systems such as NextGen and experience with CPT coding/and ICD is a plus.</li><li>Prior involvement in clinical telehealth services demonstrates adaptability to evolving healthcare models.</li><li>Experience performing procedures is desirable but not mandatory.</li></ul>Requirements:<ul><li>Minimum of 2 years experience.</li><li>Bilingual- English/Spanish a must.</li><li>Current and unrestricted Family Nurse Practitioner (FNP) license.</li><li>Active certification as a Family Nurse Practitioner through an accredited certifying body.</li><li>3 professional references with you in the last 2 years.</li><li>Recent and accurate Resume/CV.</li></ul>Why You will Love This Role:<ul><li>Competitive hourly pay</li><li>Pay increase in 6 month and 12 months (based on performance review)</li><li>Work-life balance</li><li>Consistent hours</li><li>Supportive team environment</li></ul>How to ApplyInterested candidates are required to send us a 1 minute video telling us about themselves. Send video and Resume/CV to: Ruth Hernandez (Office Manager) at ruthrod75@gmail.comPay: $64.00 - $70.00 per hourBenefits:<ul><li>Flexible schedule</li></ul>Work Location: In person

Bilingual Family Nurse Practitioner

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