Home / Chronic Care Manager Roseville Pediatrics (Full Time/Day Shift)

Chronic Care Manager Roseville Pediatrics (Full Time/Day Shift)

At Lancaster General Health, our culture is what sets us apart and creates a lasting impression of our health system in the community and in the hearts of our patients and their families. A role with us is more than just a job, we ask that you Live Your Legacy at LGH by finding your passion in your everyday role, committing to those you serve, and reaching for your personal best.

We are recognized as 1 of only 9 hospitals in the entire country with awards in Medicare.Gov, LEAPFROG and Healthgrades Americas 50 Best Hospitals. We have attained five year Magnet ® recognition status for the fifth time with the American Nurses’ Credentialing Center (ANCC) and we are the 2018 recipient of the Foster G. McGaw Prize in recognition of the commitment to community service.

PENN MEDICINE LANCASTER GENERAL HEALTH offers a comprehensive benefits package:

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program so that our employees can stay actively engaged and committed to living their legacy every day. Together, we will continue to make medical advances that help people live longer, healthier lives.

Join us and be part of a team that empowers you to do more than your job and encourages you to:

Live Your Passion. Live Your Best. Live Your Commitment. Live Your Legacy.


Job Description

HOURS: Full-Time (1.0 FTE), Day Shift with occasional Evening.

POSITION SUMMARY: Provide primary care management support to patients enrolled in the high-risk Chronic Care Clinic at Roseville Pediatrics. Uses an explicit process to identify patients at risk for poor outcomes, and who coordinates care and support, both within and outside of the pediatric primary care office. The care manager identifies problems in critical pathways, and facilitates teamwork among services required for the effective implementation of a comprehensive high-risk care model.  Integrate and work cohesively with on-going Patient Centered Medical Home primary care redesign projects.  Develop novel care management interventions with the high-risk pediatric population.

ESSENTIAL FUNCTIONS: Qualified individuals must have the ability (with or without reasonable accommodation) to perform the following duties:

  • In conjunction with the practice team, identify patients at risk for poor outcomes or experiencing poor coordination of services who would benefit from more intensive follow-up within context of the Chronic Care Clinic.
  • Conduct assessment of family and patient needs
  • Direct patient care (vaccinations, measurements, history gathering)
  • Facilitate in appointment making and coordination of information between subspecialists and the primary pediatrician. 
  • Identifies appropriate providers, facilities, external healthcare organizations, and community resources throughout the continuum of care and communicates with an interdisciplinary treatment team to develop and maintain positive working relationships with patients, families, and providers
  • Help coordinate, along with ACCT team, transportation and other socioeconomic or logistic barriers to care
  • Management of problem lists, scanned documents, dashboards, and care coordination grid within Epic for each patient in the chronic care cohort
  • Provides chronic disease and self-management education and support to patients and families
  • Interceding with insurance companies when needed for coverage and letters of medical necessity.
  • Complete care plans in coordination with parents, schools, and home based nurses.
  • Provide proactive outreach to patients to include telephonic, internet or face-to-face encounters.
  • Coordinating with the ACCT when patients are stable with current care plans and can be transitioned to the next level of care management
  • Help coordinate with the PCP for transitions of care for older patients as they transition into adult medicine and PCPs
  • Participates with the care team for data collection and collation for the purposes of health outcomes research, clinical audits,  program evaluation related to various initiatives

SECONDARY FUNCTIONS: The following duties are considered secondary to the primary duties listed above:

  • Help in identification of best methods to transmit case management plan to all points of care provided in the health care system, and county social service agencies.
  • Works together with other staff members on projects, determining scope, timeline for implementation and outcomes.
  • Participate in supporting quality improvement implementation of new forms, processes and procedures.
  • Other duties as assigned.
  • Participates in the on-call responsibilities for this position as required. 



  • Registered Nurse (RN)
  • One (1) to Three (3) year experience in case coordination and planning as well as experience in project implementation and execution
  • Ideal prior background would also include experience with insurance coordination, including tasks such as prior authorizations, pre-certifications, DME coordination, and coordination with home nursing services. Maintain current professional licensure
  • Evidence of experience working among multi-disciplinary teams.


  • One (1) to Two (2) years of care management experience, communication, and team building.

This position is located at Roseville Pediatrics #LI-MD1

Benefits of Joining Penn Medicine Lancaster General Health:

PENN MEDICINE LANCASTER GENERAL HEALTH combines a Nationally Ranked Hospital with great schools, safe neighborhoods, affordable housing, local community events and festivals as well as a wealth of cultural and recreational activities. The scenic Susquehanna River Valley provides opportunities for fishing, skiing, kayaking, hiking and mountain biking in addition to easy access to NJ shoreline or Delaware beaches. Urban life is easily accessible, with New York, Baltimore, Philadelphia and Washington D.C. a train ride away. Local universities, Fulton Theatre, the downtown shopping and dining district and local sports teams make Lancaster a great place to Live, Work and Play.


PENN MEDICINE LANCASTER GENERAL HEALTH is an Equal Opportunity Employer, committed to hiring a diverse workforce. All openings will be filled based on qualifications without regard to race, color, sex, sexual orientation, gender identity, national origin, marital status, veteran status, disability, age, religion or any other classification protected by law.


Search Firm Representatives please read carefully: PENN MEDICINE LANCASTER GENERAL HEALTH is not seeking assistance or accepting unsolicited resumes from search firms for this employment opportunity. Regardless of past practice, all resumes submitted by search firms to any employee at PENN MEDICINE LANCASTER GENERAL HEALTH via-email, the Internet or directly to hiring managers at Penn Medicine Lancaster General Health in any form without a valid written search agreement in place for that position will be deemed the sole property of PENN MEDICINE LANCASTER GENERAL HEALTH, and no fee will be paid in the event the candidate is hired by PENN MEDICINE LANCASTER GENERAL HEALTH as a result of the referral or through other means.

ROSEVILLE Full Time Posted on 11/03/2021