Chronic Care Management RN or LPN

Role:

The Chronic Care Management Nurse (CCM Nurse) will promote effective partnerships among patients, families, nurses, physicians, other qualified healthcare providers and clinical disciplines to coordinate care for patients with chronic disease and facilitate a shared goal model. The CCM nurse will provide effective clinical health coaching to assist patients with self-management of their chronic disease and life-style changes to mitigate health risks.

Essential Functions & Responsibilities:

* Perform Chronic Care Management (CCM) calls and communications with patients identified and designated by the providers under the direction of the Population Health RN (PHN).

* Make outgoing calls to CCM patients to assist patients in managing their chronic diseases - including education about their conditions and treatment regimens, medication management, appointment management with primary care and specialist providers.

* Responds to incoming telephone calls from CCM patients. Instructs patients and families regarding medication and treatment instructions.

* Maximize use of qualified clinical staff within the care management team to provide non-face-to-face patient contact

* Provide education and clinical health coaching interventions to motivate patients and families toward successful self-management of chronic disease.

* Effectively partner with the patient and provider practice team members to mobilize needed community resources for the patient and family.

* Implement, contribute to, and modify a patient care plan previously developed by the PHN based on mutual goals with the patient, family, the providers emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion and facilitate changes as needed.

* Facilitate patient access to appropriate medical and specialty providers as indicated by physician or qualified healthcare provider.

* Miscellaneous

* Participate in office meetings related to performance improvement, quarterly and annual quality reports, electronic health record enhancements, and budgeting activities.

* Attend and actively participate in all Care Coordination related training and meeting activities, i.e., Health Coach certification, quarterly Regional Workshops, scheduled webinars, cohort calls and one-on-one meetings, as needed.

* Ensure all required elements are documented for CCM and related AWV component billing.

* Ensure a high standard of nursing care to patients, while working within company policies, procedures, and nursing standards.

Additional Responsibilities:

* Will be required to establish and maintain competency in one or more of the following tasks:

* Physician Dismissals updates Practice Management (PM) and EMR records upon patient dismissal.

* Vacates and Deceased Accounts establishes new account for family member at 18 years of age, and updates accounts of deceased patients upon verification.

* Foster Child and Divorce Custody updates chart including guarantor upon obtaining valid documentation.

* Duplicate Charts consolidates duplicate charts within the PM and EMR systems

* Re-establishments reviews dismissed patient account information and determines eligibility for services.

* Performs other duties that may be assigned from time to time.