Chronic Care Manager LPN/RN

Position Summary: The CCM Manager works with Primary Care Providers (PCP), clinical staff, and care center staff to provide telephonic management of patients with multiple chronic conditions and increased risk factors to ensure excellent care is provided outside of office visits. Responsible for facilitating quality care in accordance with established clinical practice guidelines and protocol and PCP direction. Fosters patient engagement and adherence to plan of care to achieve evidence based clinical objectives and goals specific to chronic conditions and preventive health measures.


Requirements

Essential Functions: To accomplish this job successfully, an individual must be able to perform each essential function satisfactorily. Reasonable accommodation may be made to help enable qualified individuals with disabilities to perform the essential functions.


• Telephonically manage patient care, through the following methods:

o Review of the patient's medical, functional, and psychosocial needs


o Medication review for adherence


o Encourage and facilitate timely receipt of all recommended preventive services

o Reinforce disease self-management education and preventive care guidelines, communicate PCP instruction and advice, and provide patient education materials

o Referral to and coordination with community service organizations and schedule specialist appointments as needed

o Notify patients of lab results, any changes in provider orders, specialist appointments, etc. and document notification in the EMR.

o Managing care transitions between healthcare providers and settings, including assistance with referrals to outside providers, follow up after hospital or emergency room visits, or stays in skilled nursing facilities


o Facilitating patient follow-up visits with PCP for acute or chronic needs


o Document all concerns and follow-up and escalates to the Clinical Team or PCP when appropriate

• Communicate with and assist patients in a professional and courteous manner.

• Work as part of the healthcare team to assess patient needs, plan and modify care and implement interventions. Communicate with the healthcare team to provide a proactive approach to patient care.

• Obtain lab, x-ray and other reports and results, hospital notes, referral information, consults, etc. Monitor, track and resolve outstanding orders, referrals, consults, labs, procedures, etc. in EMR.

• Answer patient calls and determine how to assist them as needed. Triage patient needs and identifies necessary plan of action within office policy such as scheduling an appointment, triaging for a provider or directing the patient to the ER, etc. as needed.


• Adhere to infection control safety guidelines and confidentiality policies.

• Complete training for the Center's Electronic Health Record system

• Fulfill organizational responsibilities as assigned which include respect and promote patient's rights, respond quickly and appropriately to emergency situations and share problems relating to patients and/or team members with supervisor quickly. Provide safe, patient centered, compassionate and competent care.

• Establish and maintain effective working relationships with patients, providers, team members, insurance companies and the public. Work with peers and providers in a team environment.

• Attend training and meetings as required. Maintain annual competencies for medical assistant certification or registration or nursing license.


• Perform all other duties as assigned.


Competencies:

• Knowledge of medical terminology.

• Knowledge of medical office principles, standards, applications and tests.

• Knowledge of medical office safety, cleanliness and infection control policies and regulations.

• Decision Making - Ability to make critical decisions while following organizational policies and procedures.


• Accuracy - Ability to perform work accurately and thoroughly.

• Communication - Ability to communicate effectively verbally and in writing.

• Computer Skills - Proficient ability to use a computer and electronic medical record.

• Confidentiality - Maintain patient, team member and employer confidentiality. Comply with all HIPAA regulations.

• Customer Service Oriented - Friendly, cheerful and helpful to patients and others. Ability to meet patients and others needs while following office policies and procedures.

• Detail Oriented - Ability to pay attention to the minute details of a project or task.

• Decision Making - Ability to make critical decisions while following organizational policies and procedures.


• Flexibility - Ability to adapt easily to changing conditions and work responsibilities.

• Positivity - Display a positive attitude and is a positive agent for change.

• Teamwork - Work as part of a team and collaborate with co-workers.

• Working Under Pressure - Ability to complete assigned tasks under stressful situations.


Education and Experience:

• RN or LPN, OR Associate's Degree or higher in nursing, public health, or related field required

• Medical office experience preferred

• Experience with Microsoft Office preferred

Physical Demands:


• Frequent sitting and speaking; possible standing, walking, carrying, reaching, and bending.

• Lifting, carrying, pushing and pulling up to 15 pounds, with assistance if needed

• Frequent use of computer, keyboard, copy and fax machine and phone