LPN Chronic Care Manager

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

Job Requisition: LPNCH001999

Employment Type: Full-time

Shift: Days

Hours Per Week: 40-hour/week

Location: Broadalbin Family Health Center

Hiring Range: Starting at $25.50 hourly

Below are the shift differentials based on eligible shifts worked:

• Weekday evening shift - additional 10%
• Weekday night shift - additional 15%
• Weekend day shift - additional 10%
• Weekend evening & night shifts - additional 21%

The actual compensation for this position will be determined based on experience and other factors permitted by law.

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

Complexity of Work:

• 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.

Additional Responsibilities:

• Other duties as assigned.

Supervisory Responsibilities:

• None

Certifications / Licensure:

• NY State Licensed Practical Nurse License required

Education Training & Experience:

• Minimum of two years in Care Management or Physician Practice required.

Required Skills and Attributes:

• 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.

Required Experience:

Manager