Chronic Care Navigator - Medical Assistant

Phamily is helping to place a Chronic Care Coordinator for our client in Winterpark, FL. This individual will be working internally for our client Nephrology Associates of Central Florida (NACF), and using the Phamily platform. Phamily is a Chronic Care Platform; more information about the Care Management program can be found by clicking here: Phamily CCM 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 treatment.

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

Requirements

KEY 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 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

Monday-Friday 40 hours (8a-5p with some minor flexibility).

QUALIFICATIONS

Proven problem-solver with the ability to multitask.

Excellent communication skills, both written and spoken.

Bilingual in English and Spanish preferred.

Prior use of HER/EMR systems is highly desirable.

Medical Assistant Certification preferred.

Nephrology experience is beneficial.

$20-$23 per hour

• Health insurance
• Dental
• Vision
• 401k after a year
• Accrued PTO
• 7 paid holidays
• Ancillary benefits (short-term/long-term disability, life insurance, etc)