Chronic Care Management Specialist

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; and 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.
• 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.
• Participate in community preventative health activities i.e. school-based flu clinics.
• Will meet monthly, quarterly, and yearly metrics as indicated.
• Precepts and mentor’s 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.

Qualifications

• Minimum of 3 years of professional-level medical experience; experience in care coordination is 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 is 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.