Chronic Care Management

Job Overview

Individual will be responsible for assisting medical providers in the management of high risk, chronic illness patients to promote effective education, self-management support and timely healthcare delivery to achieve optimal quality and financial outcomes. Acts as an advocate for the individual’s healthcare needs, and coordinates care to minimize the fragmentation of health care delivery systems.

Responsibilities

• Collaborates with providers and clinic staff in identifying appropriate patients for care management, utilizing established care management criteria.
• Performs initial and periodic holistic assessments for care-managed population. This includes physical and psychological assessments as appropriate. The assessment includes a systematic and pertinent collection of data about the health status of the patient.
• Prioritize patients according to medical complexity, need and required follow up.
• Formulates and implements a care management plan that addresses the patients identified needs by assessing the patient/family needs, issues, resources and care goals; determining the choices available to individual patients; educating the patient/family on the choices available.
• Establishes a person-centered electronic care plan that is mutually agreed upon by the health care team and the patient/family. Plans will contain specific mutual self-management goals, objectives, and interventions with the patients that are action oriented.
• Evaluates the effectiveness of the plan in meeting established care goals; revises the plan as needed to reflect changing needs, issues and goals.
• Makes care conferences to discuss multidisciplinary team responsibilities, patient progress, new problems, etc.
• Identifies and effectively utilizes community resources to meet the needs of patients/families. Facilitates patient access to community resources as appropriate.
• Promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence.
• Interacts professionally with patient/family and involves patient/family in the formation of plan of care.
• Performs follow up calls for patients recently discharged from acute hospitalizations.
• Maintains EMR database on care managed population. Maintains accurate and timely documentation in the EMR.
• Reviews utilization and quality reports monthly and scans for gaps in care to identify patients needing the additional support of care management.
• Ensures all rules and requirements set forth by the Centers for Medicare and Medicaid for Chronic Care Management are being met.
• Performs medication reconciliation for all care transitions.
• Participates in community preventative health activities i.e. school-based flu clinics.
• Participates in the orientation of new personnel.
• Meets monthly, quarterly, and yearly metrics as indicated.
• Precepts and mentors peers.
• Promotes collaborative teamwork.
• Abides by the organization’s compliance program and requirements.
• Provides coverage across the organization as needed.
• Works collaboratively with leadership team to improve and enhance care delivery through the evaluation, development and enhancement of policy and procedures.
• Performs other duties as assigned.

Minimum Qualifications

• Minimum of 3 years of professional level medical experience; experience in care coordination strongly preferred.
• RN or LPN licensure preferred.
• A certified Medical Assistant with extensive care coordination experience will be considered.
• Experience working with an electronic medical record required.
• Ability to work collaboratively with people of diverse cultures and lifestyles.
• Ability to communicate effectively with providers and medical staff.
• Excellent organizational skills and ability to handle multiple priorities while remaining calm and professional.
• Ability to be self-motivating and work independently.
• Computer skills proficient to expert.
• Excellent written and oral communication skills.
• Problem solving skills.
• Proficiency in medication indications and side effects.
• Understanding of medical tests and requirements to provide the patients with appropriate information.
• Knowledge, Skills and Abilities (KSA’s): Knowledge of principles, practices, and procedures of clinical nursing. Related community health center laws and regulations. Thorough knowledge of phlebotomy, immunizations, communicable diseases, CPR, and other related nursing procedures. Thorough knowledge of mental health and substance use disorders, treatments and crisis intervention management. Ability to perform nursing duties in a professional manner. Communicate with clients, families, employees, and health care professionals. Good organizational skills to handle multiple priorities while remaining professional and calm. Ability to work with many diverse people. Effective telephone skills. Strong level of confidentiality due to the sensitivity of materials and information handled. Must be able to make suggestions on workflow or system efficiency and effectiveness. Ability to work independently and be self-directed and flexible. Ability to prioritize. Ability to perform functions with minimal supervision. Ability to work at a high-volume level of accuracy.