JOB PURPOSE:  The Chronic Care Management includes developing a comprehensive care plan that identifies a patient’s chronic health problems and goals and seeks to keep the patient in a chronic condition versus acute exacerbation.  The Chronic Care Manager position manages high risk and rising-risk patients (those patients who have identified with a certain number of chronic diseases and/or inappropriate utilization of site and service of care in primary care settings) through the development of a comprehensive care plan that helps patients become educated in their specific preventive care needs, identifies and intervenes with at-risk populations, and on-going screening/assessment of patient’s needs related to the patient’s health problems.  The Chronic care Manager works in collaboration with the Patient Health Navigator to ensure referrals to appropriate services based on the patient’s needs and care plan.

EDUCATION:  Possess at least a two (2) year higher education degree and (1) of the following: NYS Registered Nurse, NYS Licensed Practical Nurse.

LICENSURE/CERTIFICATION/REGISTRATION:  Valid NYS Registered Nurse License or Valid NYS Licensed Practical Nurse License.

EXPERIENCE:  Possess two (2) years of practice as a Registered Nurse or Licensed Practical Nurse.  If unlicensed five (5) years of progressive healthcare experience with at least three (3) years of direct patient interaction.

SHIFT:  8:00 AM – 4:30 PM                  STATUS:  40 HOURS (full-time)

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