PURPOSE:
The Chronic Care Manager is responsible for coordinating health services to patients in order to keep them healthy through wellness and prevention. This position will serve to support the Accountable Care Organization and our Chronic Care Management program by coordinating a complete plan of care. The Care Manager will support the development of this program by formulating care plans, scheduling appointments, initiating referral processing, identifying areas for expansion with chronic care, and providing medication management. The Care Manager will motivate patients and their families by eager engagement in disease management and education sessions to encourage positive behavioral modifications. This role will be responsible for ensuring billing and documentation is complete for chronic care management for eligible patients.
ESSENTIAL DUTIES/RESPONSIBILITIES:
- Orients and educates patients and their families by meeting them, explaining role of care coordinator, initiating care plan, providing education in conjunction with providers related to treatments, procedures, medications, and continuing care requirements for chronic conditions
- Marketing / Enrollment of new patients into chronic care program
- Update leadership frequently or as needed on chronic populations care progress. Communicate effectively with doctors and other healthcare professionals the status of client and their current needs.
- Provide 30-minute patient calls per day to monitor delivery of care through patient rounds, measure progress towards desired care outcomes, intervene in care deviations, and maintain ongoing communication with patient and care staff regarding care plan or transfer/discharge plans
- Facilitate reminder calls for appointments, labs, and outstanding quality improvement measures. Assist patients with appointment scheduling, referral processing, medication refills, prescription filling, and other directions from the PCP
- In collaboration with a PCP, create and modify care plans and associated goals
- Review client's preference sheet and make referrals based on need. Advocate for and provide information to patients and their families including advocacy, information and referral services to patients and families to address their medical and psycho-social needs. Provide basic health education and disease management sessions to support positive behavioral change among patients and their caregivers.
- Attend utilization management, payer, and physician meetings for updates; as needed
- Provide supplemental support for transitions of care. Collaborate with skilled nursing facilities, hospitals, and ancillary health services to support the continuum of care
- Establish relationship of trust and support that continues over time as needs of patients change. Represent Wilmington Health in a caring and professional manner to doctors and other health professionals.
OTHER DUTIES:
- Ability to investigate and analyze information and to draw conclusions.
- In-depth knowledge and understanding of the nature of chronic diseases and related issues and patient care concerns.
- Ability to design, develop, deliver, and evaluate educational programs and materials for patients and internal team members.
- Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
- Ability to establish rapport and gain the confidence of the physicians, nurses, members of the primary care team, clients, and associates.
- Ability to work independently and take initiative in addressing concerns and issues.
- Proficient with computer-based applications such as MS Office, Adobe, registries/medical databases, and electronic health record.
QUALIFICATIONS
REQUIRED:
- Registered Nurse preferred. Licensed Practical Nurse with demonstrated Chronic Care Management experience will be considered.
- Three years’ experience in care coordination or clinical practice
- Reliable transportation
- Energetic and eager to motivate others
PREFERRED:
- Fluent in English and Spanish
Required Skills
ADA PHYSICAL DEMANDS:
Rarely (Less than .5 hrs/day) Occasionally (0.6 – 2.5 hrs/day) Frequently (2.6 – 5.5 hrs/day) Continuously (5.6 – 8.0 hrs/day)
PHYSICAL DEMAND
REQUIRED?
FREQUENCY
Standing
Frequently
Sitting
Continuously
Walking
Frequently
Kneeling/Crouching
Rarely
Lifting
Occasionally
Required Experience