Chronic Care Management

Bullhook Community Health Center (BCHC) is an equal opportunity employer.  BCHC shall, upon request, provide reasonable accommodation to otherwise qualified individuals with disabilities.

Job Title : Chronic Care Management

Supervisor : CMO

Department : Medical

Supervises : N / A

Salary : $43,212.00 - $61,609.98 ($20.78-$29.62 / hr) Medical Assistant

57,204.79 - $76,878.45 ($27.50-36.96 / hr) Registered Nurse

Job Overview :

Individuals will be responsible for assisting medical providers in the management of high-risk, chronic illness patients to promote effective education, self-management support, and timely healthcare delivery to achieve optimal quality and financial outcomes. Responsibilities include coordinating patient care to improve the quality of care through the efficient use of resources and thereby enhancing quality, cost-effective outcomes. Acts as an advocate for the individual’s healthcare needs, and coordinates care to minimize the fragmentation of healthcare delivery systems. This position is committed to the constant pursuit of excellence in improving the health status of the community.

Essential Functions (Major Duties or 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. Performs Medicare Annual Wellness Visits for clients as appropriate.
• 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.
• Monitors and evaluates the progress of the patient.
• Collaborate with the healthcare team to revise the care management plan when changes occur.
• Initiates care conferences to discuss multidisciplinary team responsibilities, patient progress, new problems, etc.
• Identifies and effectively utilizes community resources to meet the needs of patients / families. Facilitates patient access to community resources as appropriate.
• Promotes patient self-management and empowers patients / families to achieve maximum levels of wellness and independence.
• Interacts professionally with patient / family and involves patient / family in the formation of plan of care.
• Performs follow-up calls for patients recently discharged from acute hospitalizations.
• 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.
• Performs medication reconciliation for all care transitions.
• Participate in community preventative health activities i.e. school-based flu clinics.
• Participates in the orientation of new personnel.
• 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.

Minimum Qualifications (Education and Experience) :

Knowledge, Skills, and Abilities (KSA’s) :

Supervision :   N / A

Physical and Environmental Demands :

Work is performed in an office and clinic setting; stands, walks with intermittent sitting; reaches for and uses writing instruments and keyboard; reads reports and other written materials; extensive use of telephone and oral communication with the public and coworkers; stoops; bends; kneels; reaches for; picks up; and pushes or pulls; ability to lift up to 30 pounds.

Special Requirements :

The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements and criteria considered necessary to perform the job successfully.

Salary : $43,212 - $76,878