Job Posting
Chronic Care Management
• 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 patient’s 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 under the direction of the Quality Measures /Chronic Care Management Coordinator by managing transitions between health care providers and settings, including referrals to other clinicians, follow-up from emergency department visits, or facility discharge.
• Will actively recruit new CCM patients and communicate effectively with providers to obtain program referrals.
• 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.
• 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.
• Documents all communication and coordination of patient contact in electronic documentation system. Assures documentation includes tracking and time stamping to support billing for CCM Services.
• 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.
• 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.
• Oversees the day-to-day operations of the CCM program and reports regularly to theQuality Measures /Chronic Care Management Coordinator.
• Orients new team members under the direction of the Quality Measures /Chronic Care Management Coordinator to CCM policies, procedures, and guidelines as directed.
• Assists in the work of quality portals to report the completion and monitoring of quality measures such as RxEffect, Stellar, etc.
• Enrich Delta Health Services Rural Health Clinic's reputation by providing high-quality service to patients and willingly taking on new tasks and assignments.
• Organizes, maintains and implements the ordering and scheduling of specialized injections. (i.e., Prolia, testosterone, etc.)
• 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 as outlined in the employee handbook, code of conduct, and expectations of all hospital personnel.
• Completes in-services and health exams as required.
Additional Information
Position Type : Full Time
Shift : Day
Contact Information
Carole Neeley - COO
Email: cneeley@deltamem.net |
