Chronic Care Case Manager
Will identify high-risk patients with at least two chronic conditions, expected to last 12 months or longer,and discuss the CCM services available.
Will obtain advance consent for CCM services to ensure that the patient is engaged and aware of applicable cost sharing. Consent may be verbal or written and documented in the medical record.
Will provide chronic care management services, at least 20 minutes of clinical staff directed by a physician, per calendar month, with the following elements: multiple (two or more) chronic conditions, chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
Will provide comprehensive care management to include systematic assessment of the patients medical, functional, and psychosocial needs, system-based approaches to ensure timely receipt of all recommended preventative care services, medication reconciliation with review of adherence and potential interactions, oversight of patient self-management of medications, coordinating care with home and community based clinical service providers.
Will provide transitional care management by managing transitions between health care providers and settings, including referrals to other clinicians, follow-up from emergency department visit, or facility discharge.
Will do a chart review monthly on CCM patients to include patient demographics, problems, medication reconciliation, allergies, review test results, preventative and follow-up care.
Constant communications to and from medical provider regarding patient needs and/or issues and to update provider on the on-going status of the patient.
Documents all communication and coordination of patient contact in electronic documentation system. Assures documentation includes tracking and time-stamping to support billing for CCM.
Will develop a comprehensive care plan that will be person-centered, electronic care plan based on physical, mental, cognitive, psychosocial, functional, and environmental (re) assessment, and an inventory of resources (a comprehensive plan of care for all health issues, with particular focus on the chronic conditions being managed).
Provide the patient and/or caregiver with a copy of the care plan.
Provides telephonic clinical expertise and oversight for chronic care management of patients, which includes frequent contact with patients to discuss the plan of care and provide patient education
Establishes and maintains positive relationships with all assigned patients and corresponding providers.
Contributes as a positive team player within the department by supporting all members of the team in a productive and constructive manner. Acts as a resource to others when needed.
Adheres to all approved company processes and procedure including documentation protocols and best practices for daily work logs, interactions with patients and providers, and internal communications.
Provides orientation to new team members as directed.
Enrich Delta Health Services Rural Health Clinic reputation by giving high-quality service to the patients and taking on new tasks with a willing approach.
Effective communication is fundamental to the existence of the clinic therefore it is important to respond to emails, electronic communication messages, voicemails and any form of communication that you receive in a timely manner.
Performs other duties as assigned.
Attends monthly staff meetings.
Is punctual and prompt for work.
Follows the policies and procedures for sick and unscheduled absences.
Adheres to the policies and procedures for Dress Code.
Completes in-services and health exams as required.
JOB SPECIFICATIONS: DESCRIPTION
1. EDUCATION Graduate of an accredited school of nursing
2. LICENSURE RN or LPN
3. EXPERIENCE At least two years experience in healthcare
4. SKILLS Experience working with an EMR system and ability to record activities into an Excel tracking
Spreadsheet. Excellent attention to detail; able to maintain complete and accurate documentation of all patients related to activities. Ability to work independently, with minimal supervision. Highly motivated, results-oriented with strong skills in customer service, organizing and multi-tasking. Flexible to handle fluctuating workloads and tasks.
5. INTERPERSONAL SKILLS Excellent written and verbal communication
skills, particularly on the phone. Ability to build relationships and quickly develop trust with patients and healthcare professionals.
6. PHYSICAL EFFORT Requires finger dexterity, eye/hand coordination and full range of body motion including the ability to stoop, kneel, crouch, reach, push, pull and grasp items and stand
Position Type : Full Time
Shift : Day
Carole Neeley - Clinic Manager
Monday thru Friday . Clinic hours .