Certified Nurse Assistant

Job Title: Certified Nurse Assistant (CNA) – Chronic Care Management Support Location: Remote (Texas-based candidates preferred) Reports To: Case Management Supervisor / CCM Program Director Client Account: FQHC Position Summary We are seeking a dedicated Certified Nurse Assistant (CNA) to join our care coordination team supporting a local FQHC Chronic Care Management (CCM) program. The ideal candidate will play a key role in engaging patients over the phone, helping develop and update care plans, and ensuring patients receive the ongoing support needed to manage their chronic conditions effectively. This position is ideal for a compassionate, detail-oriented professional with strong communication skills, proven experience using Athenahealth, and a passion for improving patient outcomes through proactive, data-driven care management.

Key Responsibilities

• Conduct monthly CCM outreach calls to eligible patients to review health goals, progress, and care plan updates.
• Document all patient interactions, interventions, and follow-up tasks accurately in Athenahealth.
• Assist in developing and maintaining personalized care plans in collaboration with RNs, case managers, and providers.
• Identify barriers to care (e.g., medication adherence, social needs, access to care) and escalate appropriately.
• Educate patients on chronic disease self-management, preventive screenings, and follow-up care instructions.
• Coordinate care transitions between primary care, specialists, and community resources.
• Support ongoing patient engagement and retention initiatives to meet CCM program performance metrics.
• Participate in daily or weekly huddles with the care management team to review caseloads and performance goals.
• Maintain strict confidentiality and compliance with HIPAA and all organizational privacy standards.

Qualifications

• Active Certified Nurse Assistant (CNA) license in the State of Texas (required).
• 2–3 years of experience in a clinical or care coordination setting, preferably within a CCM or primary care environment.
• Proficiency with Athenahealth (required) – must be comfortable navigating patient records, documentation, and care plan modules.
• Strong understanding of chronic disease management (e.g., diabetes, hypertension, COPD, CHF).
• Excellent verbal communication and active listening skills; comfortable conducting phone-based patient engagement.
• Strong organizational and documentation skills with high attention to detail.
• Compassionate, professional demeanor with a patient-first mindset.
• Ability to work independently while collaborating with a multidisciplinary care team.

Preferred Skills

• Experience with Remote Patient Monitoring (RPM), Behavioral Health Integration (BHI), or Care Coordination programs.
• Familiarity with value-based care models and population health initiatives.
• Bilingual in English/Spanish (strongly preferred).

Company Descriptionaivid Health is a Health Tech Value-Added Partner (VAP) based in Austin, Texas, committed to reimagining healthcare through innovation, collaboration, and the intelligent use of data. Our mission is to foster sustainable, healthy communities by transforming how care is delivered—breaking down silos and creating continuous feedback loops between patients, clinicians, and caregivers. We believe the real magic happens at the intersection of the human touch and the digital touch. Technology should enhance—not replace—the relationships that drive healing. We work alongside primary care providers and federally qualified health centers (FQHCs), unifying fragmented data across episodic care, remote monitoring, and social determinants of health (SDOH). Our AI-powered platform ingests structured and unstructured data from wearables, mobile apps, digital touchpoints, and clinical systems, turning it into actionable insights that fuel proactive, personalized care. By bridging the gap between insight and action, aivid Health helps clinics scale value-based care models—without drowning in complexity. We exist to challenge and disrupt without distraction, exploring the adjacent possible to make healthcare more connected, equitable, and affordable for all. Apply tot his job Apply To this Job