Chronic Care Manager (CMA, LPN or RN) (FT) | Population Health | Location vary | 2026-101

McFarland Clinic•Ames, IA

5h•Hybrid

About The Position

Collaborates with all members of the multidisciplinary healthcare team to ensure the delivery of high quality and cost effective care through provision of care management services to high risk patients in accordance with McFarland Clinic’s Core Values and Promise.

Requirements

Graduation from an accredited program for Medical Assistants OR Graduate of an accredited school of nursing.
Certification or registration from an approved certifying organization for Medical Assistants (AAMA, ARMA, AMT, NAHP, NCCT, NHA) OR Possession of a State Practical Nurse license OR Current State of Iowa Registered Nurses license.
Current Basic Life Support certification for Health Care Providers.
Mandatory Reporting of Dependent Adult and Child Abuse.
Minimum of 5 years in a multi-specialty clinic or similar organization.
Pre-employment drug screen and criminal history background checks are a condition of hire.

Nice To Haves

Experience with population health, care coordination, and/or disease management programs preferred.
Certified Health Coach preferred.

Responsibilities

For targeted patients, collaborate with the provider and patient/family to evaluate current health status, develop a patient specific care plan to reduce barriers, promote education and self care, secure needed health care and community resources, and avoid inpatient admissions and emergency department visits. Ensure care plan consistency across providers.
Communicate with targeted patients regularly and counsel on disease related symptom management, address compliance with care plans, and advise patients on lifestyle choices to improve prognosis.
Proactively connect targeted patients to payor and community health management resources and programs, as patient needs require.
Verify chronic disease conditions are accurately reflected in the electronic medical record and other disease registries as appropriate.
Provides education to targeted patients regarding all aspects of his/her care, including medication, tests, procedures, chronic condition specific information etc.
Proactively identify patients health needs, and works in collaboration with the provider, care navigator, and healthcare team to ensure preventive and /or needed care is arranged.
Participates in pre-visit planning with the provider and health care team as needed. Order tests/services due prior to office visit.
Responsible for documentation of all encounters with the patient into the EHR.
Performs other tasks as assigned by the Population Health Manager in addition to the duties of the Care Manager. These tasks are generally ongoing, require additional knowledge and skills, and reflect a higher level of responsibility.