Chronic Care Manager LPN/RN
Company: Park DuValle Community Health Centers
Location: Louisville
Posted on: February 14, 2026
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Job Description:
Job Description Job Description Description: Position Summary:
The CCM Manager works with Primary Care Providers (PCP), clinical
staff, and care center staff to provide telephonic management of
patients with multiple chronic conditions and increased risk
factors to ensure excellent care is provided outside of office
visits. Responsible for facilitating quality care in accordance
with established clinical practice guidelines and protocol and PCP
direction. Fosters patient engagement and adherence to plan of care
to achieve evidence based clinical objectives and goals specific to
chronic conditions and preventive health measures. Requirements:
Essential Functions: To accomplish this job successfully, an
individual must be able to perform each essential function
satisfactorily. Reasonable accommodation may be made to help enable
qualified individuals with disabilities to perform the essential
functions. · Telephonically manage patient care, through the
following methods: o Review of the patient’s medical, functional,
and psychosocial needs o Medication review for adherence o
Encourage and facilitate timely receipt of all recommended
preventive services o Reinforce disease self-management education
and preventive care guidelines, communicate PCP instruction and
advice, and provide patient education materials o Referral to and
coordination with community service organizations and schedule
specialist appointments as needed o Notify patients of lab results,
any changes in provider orders, specialist appointments, etc. and
document notification in the EMR. o Managing care transitions
between healthcare providers and settings, including assistance
with referrals to outside providers, follow up after hospital or
emergency room visits, or stays in skilled nursing facilities o
Facilitating patient follow-up visits with PCP for acute or chronic
needs o Document all concerns and follow-up and escalates to the
Clinical Team or PCP when appropriate · Communicate with and assist
patients in a professional and courteous manner. · Work as part of
the healthcare team to assess patient needs, plan and modify care
and implement interventions. Communicate with the healthcare team
to provide a proactive approach to patient care. · Obtain lab,
x-ray and other reports and results, hospital notes, referral
information, consults, etc. Monitor, track and resolve outstanding
orders, referrals, consults, labs, procedures, etc. in EMR. ·
Answer patient calls and determine how to assist them as needed.
Triage patient needs and identifies necessary plan of action within
office policy such as scheduling an appointment, triaging for a
provider or directing the patient to the ER, etc. as needed. ·
Adhere to infection control safety guidelines and confidentiality
policies. · Complete training for the Center’s Electronic Health
Record system · Fulfill organizational responsibilities as assigned
which include respect and promote patient's rights, respond quickly
and appropriately to emergency situations and share problems
relating to patients and/or team members with supervisor quickly.
Provide safe, patient centered, compassionate and competent care. ·
Establish and maintain effective working relationships with
patients, providers, team members, insurance companies and the
public. Work with peers and providers in a team environment. ·
Attend training and meetings as required. Maintain annual
competencies for medical assistant certification or registration or
nursing license. · Perform all other duties as assigned.
Competencies: · Knowledge of medical terminology. · Knowledge of
medical office principles, standards, applications and tests. ·
Knowledge of medical office safety, cleanliness and infection
control policies and regulations. · Decision Making – Ability to
make critical decisions while following organizational policies and
procedures. · Accuracy – Ability to perform work accurately and
thoroughly. · Communication – Ability to communicate effectively
verbally and in writing. · Computer Skills – Proficient ability to
use a computer and electronic medical record. · Confidentiality –
Maintain patient, team member and employer confidentiality. Comply
with all HIPAA regulations. · Customer Service Oriented – Friendly,
cheerful and helpful to patients and others. Ability to meet
patients and others needs while following office policies and
procedures. · Detail Oriented – Ability to pay attention to the
minute details of a project or task. · Decision Making – Ability to
make critical decisions while following organizational policies and
procedures. · Flexibility – Ability to adapt easily to changing
conditions and work responsibilities. · Positivity – Display a
positive attitude and is a positive agent for change. · Teamwork –
Work as part of a team and collaborate with co-workers. · Working
Under Pressure – Ability to complete assigned tasks under stressful
situations. Education and Experience: · RN or LPN, OR Associate’s
Degree or higher in nursing, public health, or related field
required · Medical office experience preferred · Experience with
Microsoft Office preferred Physical Demands: · Frequent sitting and
speaking; possible standing, walking, carrying, reaching, and
bending. · Lifting, carrying, pushing and pulling up to 15 pounds,
with assistance if needed · Frequent use of computer, keyboard,
copy and fax machine and phone
Keywords: Park DuValle Community Health Centers, Owensboro , Chronic Care Manager LPN/RN, Healthcare , Louisville, Kentucky
