Chronic Condition Manager - RN - Anderson, SC

About The Job

Facilitate, develop, monitor, measure, and report on wellness and chronic disease prevention and management programs that complement the Health Center maintained and coordinated by Marathon Health. The Chronic Condition Manager will educate, counsel, and coach patients on how to prevent and/or manage chronic disease in face-to-face, virtual and/or telephonic formats, as well as in one-on-one and/or group settings. The CCM may also be responsible for developing educational materials. The CCM may be asked to coordinate efforts among all client vendors to provide cohesiveness of services and to better engage the client population.

Essential Duties & Responsibilities

• Facilitates chronic condition management and prevention programs, including but not limited to: Diabetes Management, Diabetes Prevention, Hypertension Management, Hyperlipidemia Management, COPD, Asthma, Obesity and Cardiovascular Disease.
• Programs include clinical, educational, and health coaching components.
• Develops individualized interventions designed to improve and maximize health outcomes.
• Counsels and coaches patients on preventing and managing chronic diseases.
• Conducts thorough and objective evaluations of the patients’ status, including psychosocial, physical, financial, and educational needs, prognosis, and past and present treatment course and services.
• Enrolls individuals that qualify for chronic condition management programs.
• Establishes supportive and confidential relationships with patients.
• Affirms patients’ clinical and educational knowledge of chronic conditions, readiness to change behavior, and individualizes program/s based on needs.
• Collaborates with other members of the healthcare team, such as Nurse Practitioners, Physician Assistants, Medical Doctors, Health and Wellness Coaches, to optimize care and solve problems.
• Provides face-to-face, virtual and telephonic lifestyle and behavior-related health coaching in both individual and group settings.
• Reviews HRA results, if applicable, and provides education and counseling to patients based on risk factors.
• Documents in the electronic medical record, including the utilization of predictive modeling and behavior change analytics tools.
• Applies critical thinking skills and problem-solving techniques to the condition management process.
• Analyzes available data, reviews reports, and strategizes for enrollment of members to condition management programs.
• Conducts proactive outreach to members that are eligible for disease management programs, as well as to unengaged members.
• Utilizes Evidence-Based Medicine in clinical decision-making particularly with medication management, diagnostic and lab testing orders, and providing support/education to patients in making healthy lifestyle & behavioral changes.
• Completes accurate, timely and thorough documentation in EMR system.
• Supports the mission, vision, and values of Marathon Health.
• Completes all mandatory Marathon Health trainings and meetings and complies with organizational policies and procedures.
• Participates in education sessions coordinated by Marathon clients for their respective, eligible patient population.
• Coordinates efforts with other vendors (carriers, EAP, etc.) to inform client population of all available resources.
• Communicates with Marathon Corporate and/or carrier to provide compliance-related information and necessary documentation.
• Directs patients to onsite providers, primary care physicians, and/or specialists, as needed.
• Maintains current knowledge of disease processes, available resources, and treatment options appropriate to patient populations.
• Performs other duties as assigned.

Qualifications

• Registered Nurse (RN) or Bachelor’s degree in Nursing (BSN) plus a minimum 3 years’ experience in chronic disease management. (Diabetes Care, Cardiac and PulmonaryRehabilitation, etc.)
• Certified Diabetes Care and Education Specialist (CDCES) strongly preferred.
• Desired Attributes:
  • Passionate about transforming the way healthcare is delivered.
  • Passionate about the patient experience.
  • Desire to improve the quality of care for people.
  • Enjoy working in a collaborative team environment where patients come first.
  • Entrepreneurial spirit and a passion for creating and driving best practices.
  • Willingness to go the extra mile for patients.
  • Great customer service skills.
  • Able to work autonomously.
  • Demonstrated competence in multi-tasking.
  • Excellent critical thinking skills.
  • Experience leading and developing presentations.
  • High energy personal style and aptitude for process-oriented thinking.
  • Track record of consistent, stable employment along with the ability to work independently and as a part of a team.

Pay Range

$75,000 - $90,000/yr. The actual offer may vary dependent upon geographic location and the candidate’s years of experience and/or skill level.