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Chronic Care Management Nurse (Medical Assistant)


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Title: Chronic Care Management Nurse (Medical Assistant)

Facility: Kearney, Nebraska

Reports To: VP of Clinical Services

Status: Full-Time


Position Summary:

The Chronic Care Management Medical Assistant provides outreach communication with patients and families enrolled in our Chronic Care Management Program by assessing chronic conditions, reconciling medications as well as reviewing and updating care plans under the direction of the physician and coordination with the care teams to help the patient meet their goals. Compliance with rules and regulations of all applicable federal, state and local laws as well as ruralMED policies is a condition of employment.


Job Duties:

Incumbent must have the skills, ability and judgment to perform the following essential job duties and responsibilities with or without reasonable accommodation:

  1. Assesses data regarding the patient’s physical, psychological, social and spiritual dimensions based on the patient’s age and development.
  2. Reports and documents all observed symptoms, reactions and changes in the patients’ condition to the Physician, APC and/or Registered Nurse as appropriate.
  3. Assessing/Enrolling patients in the CCM program.
  4. Creates nursing interventions as needed/required to help patients meet goals outlined in the provider’s care plan.
  5. Communicates with staff nurses, providers and program managers to address any and all issues with patients enrolled in the CCM program.
  6. Reviews assigned patients on a monthly basis.
  7. Documentation in the EMR to ensure compliance with the CCM program.
  8. Assists in the development, implementation, revision and evaluation of a formal plan of care for patients enrolled in our program.
  9. Provides assistance to the Operating Practitioner and assists in the nursing process to direct and deliver patient care.
  10. Creates and maintains a comfortable and safe environment for patients, visitors and other employees.
  11. Organizes and prioritizes daily assignments to provide optimal patient care and increase productivity.
  12. Conforms and complies with ruralMED Management Resources Codes of Conduct and with procedures, regulations and rules in maintaining medical records.
  13. Maintains patient and employee confidentiality at all times.
  14. Demonstrates competency annually in assigned areas of work.
  15. Other duties as assigned/needed.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Regularly required to use hands to finger, handle or feel objects, tools or controls; reach with hands and arms; and talk and hear; regularly required to sit, stand, kneel and walk, including walking up several steps. The employee is occasionally required to reach with hands and arms, stoop, kneel, crouch or crawl, climb or balance, and taste or smell. The employee must regularly lift and/or move up to 20 pounds and occasionally lift and/or move up to 40 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.


Required Education:

High school diploma or equivalent.
Must have successfully completed and graduated from a medical assistant program.


Licenses/Certifications Required:

  • Current BLS/CPR certification.