Chronic Care Management RN

Hot Springs Health Clinics

Chronic Care Management RN - Remote

Job Description

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DEPARTMENT:        Hot Springs Health Clinics

SUPERVISOR:          Director Nursing Service - Clinics

EMPLOYEE NAME:

APPROVED BY:       Director Clinic Operations                             DATE: February 2025

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GENERAL:

In accordance with the Hot Springs Health Personnel Policy and Procedure Manual and the requirements of our accrediting bodies, the employee will: support the mission “Partnering with our community for quality health and healing”, the five core values “Ownership, Always Better Than Yesterday, Service First, Integrity, and Stewardship of Our Resources (OASIS)”.  Our behavior creates our OASIS – a place where we can find safety, sustenance, and a pleasant change from the usual and vision of “being the provider and employer of choice in our region, providing the highest quality care and excelling as a teaching hospital in Wyoming.”

The established priorities of Quality, Service, Finance, People, and Growth, will be utilized in decision making. Furthermore, the employee will demonstrate the ability to manage time, maintain a safe and clean environment; practice confidentiality; treat all persons with respect and professional courtesy; accept change; accept and provide constructive feedback; work as a team player and adhere to the infection control, fire and safety, disaster and hazardous waste policies.  The employee must also demonstrate the competencies for their position, and adhere to policies and procedures of their department. The employee will participate in quality improvement activities.

BEHAVIORAL REQUIREMENTS:

The following is a list of minimally required behaviors to assist the employee in partnering with our community:

Ownership

Accepts responsibility for actions, attitudes and health.  Doing things right the first time, every time for excellent results.  Accepts ownership of mistakes and takes constructive action to avoid repeating mistakes.  Works with empowerment to the highest potential both as an individual and as part of the team. Unsatisfied with the status quo or just being “good.” 

Always Better Than Yesterday

Performs at the highest level, always learning and looking for ways to improve, with an unwavering focus on safety.  Celebrates and encourages the contributions of one another. 

Constructively challenges the status quo by being flexible, adaptable and embracing change as a key element of our future success. Contributes to an environment that encourages creative thinking.  Shares ideas and opinions, and supports opportunities to learn and grow.

Service First

Doing our best every day to anticipate and exceed the expectations of patients, providers and co-workers. Understands excellence is the result of team effort.  Creates legendary experiences.

Integrity

Does the right things.  Consistently open, honest, trustworthy and ethical.  Demonstrates respect for patients, their families, staff, providers and the community. 

Stewardship of Our Resources

Strives to care wisely for our human, financial and natural resources.  Strengthens HSH as a partner in the community.    

POSITION SUMMARY:  The Chronic Care Management Registered Nurse will work in collaboration with intra and inter departmental staff of the organization, outreach, disease management/care management, care coordination/health promotion, education/training and motivational support to patients, referral sources and the community.   This position will work to improve the quality of life of patients enrolled through supporting quality outcomes, smooth care transitions, coordination of care across the health continuum, encourage healthy lifestyle choices to reduce long term effects of chronic illness. This position is accountable for working with the Chronic Care Coordinator and representing our clinics across multiple constituents.

POSITION STATUS: This position is a Non-Exempt position. Generally expected to work 5 days a week

ESSENTIAL DUTIES AND RESPONSIBILITIES:

1. Exhibit competence consistent with the level of training and education as an CCM RN in the Seven Domains of Care Coordination in the primary care setting: 
   1. Population Health Management,
   2. Comprehensive Assessment and Care Planning,
   3. Interpersonal Communication,
   4. Education/Coaching,
   5. Health Insurance and Benefit knowledge,
   6. Community Resource knowledge and
   7. Research and Evaluation skills.
2. Remains current on industry trends, best practice operational models, and changing patient and provider needs.
3. Analyzes clinical data generated from EHR/Registry system and identifies patients who have gaps in care and utilizes risk stratification intervention metrics for care coordination recruitment purposes.
4. As directed, provides outreach, disease management, education, and other needed activities to patients with various chronic health conditions and to referral sources and community.
5. Provide outreach, disease management, education and other needed clinically based activities to patients managing various chronic health conditions and to referral sources and community.
6. Assess and identify participant’s readiness, willingness, and ability to change.
7. Identify patient coaching, support, and educational needs by focusing on what is important to their quality of life.
8. Conduct health and wellness coaching sessions to assist participants in making lasting changes to their health and wellness.
9. Collaborate with the patient to develop a plan of care including goals and interventions for behavioral modification within the scope of nursing practice.
10. Monitor and document the patient’s progress toward his or her optimal level of wellness.
11. Determine and connect with relevant community and/or health care resources to support solutions; provide educational tools to promote self-management.
12. Act as a liaison between referral sources, facilities, and outside entities to prevent and/or resolve continuum of care issues
13. Communicate with service delivery partners, providers, and other health professionals to provide care coordination to ensure the plan of care facilitates the efficient use of health care resources.
14. Proactively follow up with patients discharged from all hospitals, rehab facilities and emergency rooms to recruit patients into the care management services to ensure patient has an appointment with their provider and reviews any unmet needs prior to the upcoming appointment.
15. Other duties as assigned.

The above duties are intended to describe the key aspects of the work performed by individual(s) assigned to this position. They are not to be construed as an exhaustive listing of requirements relative to the position. Therefore, the employee may be required to perform other duties as assigned.       

QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE

1. Unencumbered Registered Nurse license in the State of Wyoming or with the ability to obtain a Wyoming License.
2. Previous care coordination experience preferred
3. Previous clinical experience including working with the geriatric population preferred
4. Previous work experience with patient engagement, patient coaching, and patient education preferred

LANGUAGE SKILLS:

Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents. Ability to respond to common inquiries or complaints from customers or members of the business community. Ability to read and interpret policies and procedures. Ability to effectively present information to community members, public groups, and/or boards of directors.

MATHEMATICAL SKILLS:

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and is knowledgeable in metric, apothecary and household measurements and can convert from one system to another.

COMPUTER SKILLS:

Ability to operate various software applications including by not limited to electronic medical records, care coordination platforms and video technology.  Ability to assist and educate patients in the use of telehealth equipment.

REASONING ABILITY:

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Ability to modify care based on the developmental / functional age of the patient as well as that of the patient's ethnic background including seeking advice and or direction as needed.

CERTIFICATES, LICENSES, REGISTRATIONS:

OTHER SKILLS AND ABILITIES:

Ability to act as a patient advocate.  Ability to positively interact with patients, families, visitors, and co-workers.  Ability to interact assertively and tactfully when dealing with conflict and in group solving activities.  Ability to demonstrate a professional, open minded approach in identifying problems and resolving problems/conflicts. Ability to develop creative solutions outside of the health care setting. Ability to develop relationships with community resources. Ability to appropriately manage time and work in flexible environments. Ability to work under a self-directed model and meet demanding deadlines.

Age Specific:

Must be able to provide care according to the developmental level and or chronological patient served.  This includes, but is not limited to, identifying the needs and abilities of each patient, and demonstrating an understanding of how a patient’s chronological and developmental age influences his/her need for adaptations related to his/her abilities.  Also, an understanding of how a patient’s age impacts his/her ability to deal with and adapt to the care needed/provided is required.  General census of neonatal to geriatric patients.

PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While filling this position, the employee must regularly lift and or move 10 pounds and occasionally lift and/or move up to 50 pounds.  Specific vision abilities required by this position include close vision, distance, vision, color vision, peripheral vision, and depth perception.  This position also requires walking or standing to a significant degree.  This position also requires reaching, handling, fingering, feeling, talking, and hearing, stooping, bending, crouching, and working with equipment.

WORK ENVIRONMENT: The work environment characteristics described here are representative of those employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The employee is subject to inside and possibly outside weather conditions. The employee is also subject to exposure to blood and body fluids, proximity to moving mechanical parts, electrical shock, exposure to burns and radiant energy, exposure to toxic chemicals and biological agents.