Care Management Clinical Staff

DescriptionCare Management Clinical Staff Member (CMA, CNA, or LPN)We are seeking a compassionate and detail-oriented Certified Medical Assistant (CMA), Certified Nursing Assistant (CNA), or Licensed Practical Nurse (LPN) to join our Care Management Team. This role plays a vital part in our population health initiatives by conducting proactive, telephone-based cognitive screenings for Medicare patients aged 65 and older. The ideal candidate will help bridge the gap between in-office screening efforts and our expanding older adult patient panel, ensuring timely identification of cognitive concerns and facilitating appropriate follow-up.Key Responsibilities Conduct proactive telephone-based cognitive screenings for preselected Medicare patients aged 65 and older who have not had a documented cognitive assessment in the past 12 months. Document screening results accurately and thoroughly in the patient’s health record. Identify and refer patients with potential cognitive concerns to licensed clinical staff for further evaluation. Maintain confidentiality and adhere to all privacy and security protocols. Collaborate with the Care Management Team to support population health goals and improve patient outcomes. Follow established protocols and scripts to ensure consistency and quality in screening procedures.Skills And Qualifications Certification as a Medical Assistant (CMA), Nursing Assistant (CNA), or licensure as a Licensed Practical Nurse (LPN). Excellent communication skills, with the ability to engage patients effectively over the phone. Strong organizational skills and attention to detail. Ability to work independently and as part of a multidisciplinary team. Understanding of population health principles and the importance of preventive care. Prior experience in a healthcare setting preferred but not required. Compassionate, patient-centered approach with a focus on quality and accuracy.Join our dynamic team dedicated to improving the health and well-being of our older adult population. We offer a collaborative work environment, opportunities for growth, and a commitment to making a meaningful difference in patient care.RequirementsScreening — the primary function Works from the monthly preselected patient list to conduct outbound telephone calls to patientsaged 65 and older who are due for cognitive screening. Administers the telephone-modified Mini-Cog (3-word recall) following the Telephone CognitiveScreening Protocol verbatim. Uses no clinical judgment in scoring — applies the single scoring rule aswritten and documents the result. Documents every call outcome in athenaOne within 2 hours, using the structured documentationtemplate. No exceptions. Flags all positive screens in athenaOne immediately and notifies the supervising clinician or lead caremanager via athenaOne task the same business day. Handles all call dispositions per the protocol — patients who decline, are unreachable, cannotcomplete the screen by telephone, or are already diagnosed. Maintains a daily call log tracking calls attempted, screens completed, positive screens, anddispositions. Submits weekly to the lead care manager.Scheduling support Contacts patients with positive screens to schedule a 99483 Cognitive Assessment visit within 3weeks. Confirms that an independent historian will accompany the patient. Makes follow-up calls to patients awaiting 99483 visits to confirm appointments and reduce no-shows.Population outreach support Assists with population-level outreach as capacity allows — AWV scheduling, post-hospitalization check-ins, caregiver support calls.