Chronic Care Management

Chronic Care Management

Role:

The telephone Chronic Care Management Nurse (CCM) 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 Practice Transformation Director.
  • 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 based on mutual goals with the patient, family, the providers, 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.
  • Bill for CCM per CMS guidelines.

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, workshops, scheduled webinars, cohort calls and one-on-one meetings, as needed.
  • Ensure all required elements are documented for CCM billing.
  • Ensure a high standard of nursing care to patients, while working within company policies, procedures, and standard of care.

Qualification:

• Medical Assistant
• Significant experience within a primary care setting with quality/population health experience in lieu of certification will be considered.
• Experience working in an EMR, which is required.
• Demonstrate active listening skills and communicate effectively both written and verbally.
• Excellent time management skills
• Excellent communication skills
• Well-versed in privacy policies and maintain the confidentiality of personal health information for all patients.
• Adhere to the highest standards of personal and professional conduct.

Qualification

• A minimum of two years providing nursing care to chronically ill patients, especially in home health or primary care settings.
• Experience working in an EMR, which is required.
• Demonstrate active listening skills and communicate effectively both written and verbally.
• Excellent time management skills
• Well-versed in privacy policies and maintain the confidentiality of personal health information for all patients.
• Adhere to the highest standards of personal and professional conduct.