Job Description

Salary:

POSITION SUMMARY:

Under supervision of the Clinical Coordinator, the Chronic Care Management Nurse is responsible for managing a caseload taken from a population of individuals that meet clinical requirements for Chronic Care Management (CCM); working closely with clinical support staff, nursing leadership, physicians, and the population health department to achieve system goals of improving clinical outcomes for patients with chronic diseases; developing processes that support the CCM program, and ensuring all requirements have been met in order to bill and receive reimbursements that support the program for continued growth.

RESPONSIBILITIES:

Will provide pre-visit planning for overdue cancer screenings for all patients who are on the schedule within the next 48 hours. For example:
- Patients who are on the schedule for Wednesday, would have their pre-visit planning complete the Monday prior.
- Patients who are on the schedule for Thursday, would have their pre-visit planning complete the Tuesday prior.
Actions would be put in place in the electronic health record for the provider and provider’s nurse for the date of the patients scheduled appointments for any overdue screening
Receive referrals within Electronic Medical Record System, ensure required documentation is within patient’s chart or contact to obtain required information, and contact patients to schedule intake appointments accordingly:
- Make appts for referrals.
- Get notes back.
- Set action to remind when patient is to go back to specialist to get note.
Assist providers with patient care by making calls to assist the patient adherence to treatment plan goals.
Establish and manage follow-up appointment schedules and monitor patient progress and engagement by appointment confirmation calls, reminder calls, outreach letters, etc.
Instruct and educate patients on procedures, healthcare provider instructions, and referrals.
Link patients to social services programs and entitlements such as transportation assistance and translation service.
Participate in Quality Improvement, Quality Assurance activities as appropriate for departmental tracking.

CERTIFICATIONS AND QUALIFICATIONS:

Certification of practice as a Licensed Practical Nurse or Registered Nurse.
Sufficient experience to carry out the duties of this position.
Must be qualified in Basic Life Support techniques.
Ability to relate with warmth and effectiveness to the patients and to the providers of the community health center.
Participate in on-going age-related in-service training for patients in various age-groups.

Significant experience considered.
Ability and willingness to function independently and proactively in a primary health care setting.
Ability and willingness to work in a time-limited, structured, and solution-focused environment with ability to be flexible and adapt to unforeseen needs or circumstances.
Possess excellent time management skills and ability to prioritize daily tasks
Strong interpersonal and skills
Must possess excellent verbal and written communication skills with the ability to listen and ability to use language confidently and appropriately.
Ability to communicate clearly and concisely in writing.
Ability to actively attend to, convey, and understand the comments and questions of others.
Comfortable with patient-centered care approach to incorporate patient’s desires to inform the plan of changes.
Ability to utilize electronic communication tools to include but not limited to: telephone, computer, electronic medical records system, Microsoft Word and Microsoft Excel.
Ability to serve as liaison to facilitate connections between people in a collaborative role.
Ability to provide accurate feedback about behavioral risks and disorders without judgement or discomfort.
CPR certification.

EVALUATION:

The evaluation of work performance will be on-going, and will be carried out by the physician in charge at the clinic assigned, and will include the specific duties and responsibilities of this position description plus employee attitudes and general working behavior. Formal evaluation will normally be performed annually, but may be initiated at other times by the Clinical Coordinator or the Chief Nursing Officer.

STATUS:

This is a FLSA NonExempt position.

This is an OSHA low risk position.

This is an ADA negotiable position.

This is a safety sensitive position.

Mid-Delta follows state and federal vaccine recommendations.