LPN Chronic Care Manager

St. Mary's Healthcare • Amsterdam, NY

3d • Onsite

About The Position

St. Mary’s Healthcare has been providing high-quality, compassionate healthcare to the people of Montgomery and Fulton counties since 1903. At St. Mary’s Hospital, the Rao Outpatient Pavilion and other locations, the local, independent healthcare organization offers the comprehensive, critical services its community needs and deserves. St. Mary’s Healthcare has also been named a 2026 Times Union Top Workplace—the first acute care hospital in the Capital Region to earn the distinction since the Times Union launched the recognition program 14 years ago.

This role requires strong critical thinking, clinical judgment, and the ability to work independently within scope of practice. The Chronic Care Manager must manage competing priorities, remain organized, and adapt to changing patient and program needs in a fast-paced ambulatory care environment. The position requires flexibility to provide coverage across sites as needed.

Requirements

• NY State Licensed Practical Nurse License required
• Minimum of two years in Care Management or Physician Practice required.
• Ability to organize and establish day-to-day priorities while utilizing critical thinking skills in all aspects of the job.
• Must be able to multitask while remaining professional, focused, composed and positive.
• Excellent customer service skills and must display integrity, friendliness, and compassion.
• Must be able to establish an appropriate and effective rapport with others.
• Must be flexible to take initiative and embrace new opportunities to grow both personally and organizationally.
• Problem solving skills.
• Proficient with Microsoft Office products: Outlook, Word, Excel
• Strong organizational skills.
• Effective interpersonal skills.
• Ability to work as part of a team and independently.
• Must be able to speak, read, write and follow instructions in English.

Responsibilities

• Provide comprehensive care management services to a panel of complex patients, including development, implementation, and ongoing management of individualized care plans in collaboration with patients, families, providers, and interdisciplinary teams.
• Support patients across the continuum of care, including transitions following hospital, rehabilitation, or skilled nursing facility stays, with a focus on improving outcomes and reducing avoidable utilization.
• Deliver patient-centered education related to chronic disease management, medications, and self-care, while addressing medical and social determinants of health through coordination of appropriate resources and services.
• Maintain accurate, timely documentation within the EMR and complete monthly Chronic Care Management billing requirements in alignment with program guidelines and regulatory standards.
• Ensure ongoing patient engagement, communication, and access to care management services, while adhering to CMS Chronic Care Management requirements including consent, care plan management, and care coordination activities.
• Collaborate effectively with providers, care teams, and community partners to support continuity of care and promote program goals.
• Other duties as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed