Chronic Care Management Nurse

The Chronic Care Nurse performs care management for chronically ill patients with chronic diseases such as but not limited to hypertension, chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, and/or congestive heart failure. The Care Specialist works in collaboration and continuous partnership with chronically ill patients and their family/caregiver(s), clinic providers and community resources in a team approach to increase patients’ ability for self-management and shared decision-making. The Care Specialist coordinates care and is a very detailed position. The responsibilities of this position are very crucial to patients and the practice.

II. RESPONSIBILITIES:

1. Contributes to telephone counseling and education per month to each CCM patient on calendar.

2. Complies with documentation requirements of the Chronic Care Management program by carrying out details and recording in the EHR.

3. Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, and facilitates changes as needed.

4. Creates an ongoing process for patient and family/caregivers(s) to determine and request the level of care coordination support they desire.

5. Coordinates transition of inpatient to outpatient care in an effort to decrease readmission rates, Transitional Care Management.

6. Works closely with in-office providers to manage the day-to-day calls involving: symptom control, medication management, and provide patient and family education.

7. Assist with the identification of “high-risk” patients (the chronically ill and those with special health care needs) and assist on the enrollment of these to the patient registry.

8. Coordinates continuity of patient care with external healthcare organizations and facilities including from the primary care provider to a specialty care provider.

9. Supports patient self-management of disease and behavior modification interventions.

10. Provides patient health counseling, education and instruction.

11. Any other tasks, assignments, projects, or requests as deemed by management as assigned.

III. EDUCATION and/or EXPERIENCE

1. LVN or RN license required.

2. Minimum of 1 year work experience in a healthcare setting involving patients with chronic disease states preferred.

SKILLS:

1. Strong working knowledge of chronic disease including but not limited to chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, and congestive heart failure and basic medical management.

2. Must be highly motivated, result-oriented with strong skills in presenting, communicating, organizing, multi-tasking and time management skills

3. Strong organizational and interpersonal skills

4. Excellent customer service skills demonstrated by positive feedback from patients/team.

5. Ability to identify problems and recommend solutions

6. Ability to read, write and communicate effectively orally and in writing

7. Basic computer skills including previous work with an electronic health record (EHR)

Job Type: Full-time

Pay: From $23.00 per hour

Expected hours: 40 per week

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Medical Specialty:

• Primary Care

Physical Setting:

• Clinic

Supplemental Pay:

• Bonus opportunities

Work Location: In person

Salary : $23