Chronic Condition Manager - RN - Anderson, SC

Marathon Health is a leading provider of advanced primary care in the U.S., serving 2.5 million eligible patients through approximately 630 employer and union-sponsored clients. Our comprehensive services include advanced primary care, mental health, occupational health, musculoskeletal, and pharmacy services, delivered through our 680+ health centers across 41 states. We also offer virtual primary care and mental health services accessible in all 50 states. Transforming healthcare delivery with a patient-first approach, we prioritize convenient access to both in‑person and virtual care, resulting in improved health outcomes and significant cost savings. Committed to inclusivity and collaboration, we foster a positive work environment and recruit exceptional talent to ensure expertise and compassion in healthcare delivery. Marathon has been recognized as a five-time Modern Healthcare Best Places to Work in Healthcare winner and a six-time Best in KLAS award winner for employer-sponsored healthcare services.

ABOUT THE JOB

Facilitate, develop, monitor, measure, and report on wellness and chronic disease prevention and management programs that complement the Health Center maintained and coordinated by Marathon Health. The Chronic Condition Manager will educate, counsel, and coach patients on how to prevent and/or manage chronic disease in face‑to‑face, virtual and/or telephonic formats, as well as in one‑on‑one and/or group settings. The CCM may also be responsible for developing educational materials and coordinating efforts among all client vendors to provide cohesiveness of services and better engage the client population. These duties are carried out for a specific client at its various locations.

ESSENTIAL DUTIES & RESPONSIBILITIES

Facilitates chronic condition management and prevention programs, including but not limited to Diabetes Management, Diabetes Prevention, Hypertension Management, Hyperlipidemia Management, COPD, Asthma, Obesity and Cardiovascular Disease. Programs include clinical, educational, and health coaching components. Develops individualized interventions designed to improve and maximize health outcomes. Conducts thorough and objective evaluations of the patients’ status, including psychosocial, physical, financial, and educational needs, prognosis, and past and present treatment course and services. Identifies and enrolls individuals that qualify for chronic condition management programs. Establishes supportive and confidential relationships with patients. Assesses patients’ clinical and educational knowledge of chronic condition, readiness to change behavior and individualizes program(s) based on needs. Collaborates with other members of the healthcare team, such as Nurse Practitioners, Physician Assistants, Medical Doctors, and Health and Wellness Coaches, to optimize care and solve problems. Conducts outreach via phone, email and regular mail. Provides face‑to‑face, virtual and telephonic lifestyle and behavior‑related health coaching in both individual and group settings. Reviews HRA results, if applicable, and provides education and counseling to patients based on risk factors. Follows workflow and policy guidelines for documentation in the electronic medical record, including the utilization of predictive modeling and behavior change analytics tools. Applies critical thinking skills and problem‑solving techniques to the condition management process. Participates in the analysis of available data, review of reports, and strategy for enrollment of members to condition management programs. Performs in‑person, virtual, telephonic, and/or electronic proactive outreach to members that are eligible for disease management programs, as well as to unengaged members. Utilizes Evidence Based Medicine in clinical decision making particularly with medication management, diagnostic and lab testing orders, and providing support/education to patients in making healthy lifestyle & behavioral changes. Completes accurate, timely and thorough documentation in EMR system. Supports the mission, vision, and values of Marathon Health. Participates in and completes all mandatory Marathon Health trainings and meetings and complies with organizational policies and procedures. Participates in education sessions coordinated by Marathon clients for their respective, eligible patient population. Coordinates efforts with other vendors (carriers, EAP, etc.) to inform client population of all available resources. Communicates with Marathon Corporate and/or carrier to provide compliance‑related information and necessary documentation. Directs patients to onsite providers, primary care physicians, and/or specialists, as needed. Maintains current knowledge of disease processes, available resources, and treatment options appropriate to patient populations. Performs other duties as assigned.

QUALIFICATIONS

Registered Nurse (RN) or Bachelor’s degree in Nursing (BSN) plus a minimum 3 years’ experience in chronic disease management (Diabetes Care, Cardiac and Pulmonary Rehabilitation, etc.). Certified Diabetes Care and Education Specialist (CDCES) strongly preferred.

DESIRED ATTRIBUTES

Passionate about transforming the way healthcare is delivered. Passionate about the patient experience. Desire to improve the quality of care for people. Enjoy working in a collaborative team environment where patients come first. Entrepreneurial spirit and a passion for creating and driving best practices. Willingness to go the extra mile for patients. Great customer service skills. Ability to work autonomously. Demonstrated competence in multi‑tasking. Excellent critical thinking skills. Experience leading and developing presentations. High energy personal style and aptitude for process‑oriented thinking. Track record of consistent, stable employment along with the ability to work independently and as a part of a team. Pay Range $75,000 - $90,000/yr The actual offer may vary dependent upon geographic location and the candidate’s years of experience and/or skill level. Marathon Benefits Summary Health and Well‑Being: Free Marathon membership for in‑person and virtual care, employer paid life and disability insurance, and choice in medical/dental plans, vision, employer funded HSA, FSA, and voluntary illness, accident and hospitalization plans. Benefits are effective on the first of the month following date of hire. Financial Support: Competitive compensation, 401k match, access to financial coaching through our Employee Assistance Program. Lifestyle: Paid time off for vacation, sick leave, and more, holiday schedule. #J-18808-Ljbffr Marathon Health Inc