Chronic Care Management (CCM) Nurse

JOB SUMMARY: 

The Chronic Care Management Nurse is responsible for assessing, planning, implementing, and evaluating healthcare services for long term care residents with chronic medical needs. This role involves collaborating with interdisciplinary teams, residents, families, and external healthcare providers to ensure comprehensive and coordinated care. The nurse will focus on optimizing the health and well-being of residents with chronic illnesses, multiple comorbidities, and other healthcare requirements. 

ESSENTIAL DUTIES and RESPONSIBILITIES: 

      Billing and Documentation: 

• This role also includes ensuring that Chronic Care Management (CCM) services meet CMS documentation and billing requirements for Medicare Part B. The nurse will oversee the implementation of care coordination efforts, optimize the use of CCM services, and assist in reducing hospitalizations by managing transitions of care. 

• Ensure compliance with CCM documentation requirements, including at least 20 minutes of clinical staff time per patient per month. 

       Assessment and Planning: 

• Conduct thorough assessments of residents with chronic medical conditions, including medical history, physical examination, and psychosocial factors. 

• Develop individualized care plans in collaboration with residents, families, and healthcare teams, considering the unique needs and preferences of each resident. 

      Coordination and Collaboration: 

• Work closely with the interdisciplinary team to provide non-face-to-face CCM services, including coordinating specialist referrals, medication management, and ongoing monitoring of chronic conditions. 

• Act as a liaison between residents, families, and healthcare professionals, advocating for the best interests of the residents. 

      Care Implementation: 

• Oversee the implementation of care plans, ensuring that interventions are carried out effectively and in a timely manner. 

• Provide direct nursing care as needed, especially for residents with acute exacerbations or changes in health status. 

      Education and Support: 

• Educate residents and their families on managing chronic medical conditions, medications, and treatment plans. 

• Provide emotional support and counseling to residents and families dealing with the challenges of chronic illnesses. 

      Monitoring and Evaluation: 

• Regularly monitor and evaluate the effectiveness of care plans, making adjustments as necessary to meet changing healthcare needs. 

• Document all care interventions, changes in resident status, and communication with healthcare providers. 

      Quality Improvement: 

• Participate in quality improvement initiatives to enhance the overall healthcare services provided in the long-term care facilities. 

• Collaborate with the leadership team to identify and address areas for improvement in complex care management. 

      Qualifications: 

• Registered Nurse (RN) with a valid license. 

• Bachelor's degree in nursing (BSN) preferred. 

• Certification in Gerontology or Chronic Care Management (CCM) is preferred. 

• Preferred experience working with Medicare Part B Chronic Care Management programs, care coordination, or CMS quality reporting is highly desirable. 

• Strong clinical assessment and critical thinking skills. 

• Excellent communication and interpersonal skills. 

• Ability to work collaboratively in a team and independently. 

      Physical: 

• Walking and standing for long periods of time. 

WORKING ENVIRONMENT: 

The Chronic Care Management Nurse primarily works within the long term care communities, interacting with residents, families, and healthcare professionals. This role may involve occasional travel to facilities or coordination meetings outside the onsite location. 

Benefits: 

• Competitive salary with medical, dental, and vision, short term disability and life insurance for employees and dependents. 

• 401K matching, generous vacation time, and paid holidays. 

About Us: 

Join Oak Medical’s team and be part of a growing organization that values collaboration, compassion, and clinical excellence. Oak Medical focuses on empowering healthcare professionals through robust administrative support so you can concentrate on providing the best possible care.  

At Oak Medical, we are creating consistent access to high quality care in the most efficient manner for patients, family members, and health care professionals in specialty hospitals, skilled nursing facilities and senior living communities. Our physicians, advanced practice and specialty providers deliver onsite services with a care team focused on timely, dignified, and compassionate care delivery. We do this through a value driven framework of safe and exceptional patient care, accountability, kindness, mentorship, excellence and dedication.   

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, pregnancy, age, national origin, disability status, genetic information, protected veteran status, or any other characteristic protected by law.