Chronic Care Manager, RN/LPN

2 months ago

Lawrence, United States Heartland Community Health Center Full time
Job DescriptionJob DescriptionSalary: $23.60 - $37.00


Welcoming all who need care

 

Job title 

Chronic Care Manager (CCM)

Reports to 

Director of Clinical Services

Status 

Non-Exempt (Hourly)

 

Job purpose 


The Chronic Care Manager (CCM) is responsible for overseeing and coordinating the care of patients with chronic health conditions, such as diabetes, hypertension, heart disease, and respiratory disorders. Working closely with the healthcare team, including providers, nurses, social workers, and other allied health professionals, the Chronic Care Manager will develop personalized care plans, monitor patient progress, and provide ongoing support to ensure the best possible health outcomes.

 

Duties and responsibilities 

  • Patient Assessment: Conduct comprehensive assessments of patients with chronic conditions to identify their specific needs, health status, and potential barriers to care.
  • Care Planning: Collaborate with the healthcare team to develop individualized care plans that align with evidence-based guidelines and address the patient's unique health challenges and goals.
  • Care Coordination: Serve as the central point of contact for patients with chronic conditions, coordinating and facilitating communication among healthcare providers, specialists, and community resources.
  • Patient Education: Provide patients with comprehensive education on their chronic conditions, treatment plans, self-management strategies, and preventive measures.
  • Medication Management: Monitor patients' medication adherence, review medication regimens for effectiveness, and address any potential drug interactions or side effects.
  • Health Monitoring: Regularly monitor patients' health status, including vital signs, lab results, and symptoms, and adjust care plans as needed to achieve optimal health outcomes.
  • Support for Self-Management: Empower patients to take an active role in managing their chronic conditions by promoting healthy lifestyle choices, self-monitoring, and adherence to treatment plans.
  • Health Promotion: Develop and implement health promotion initiatives to prevent the onset of chronic conditions and improve overall community health.
  • Data Management: Maintain accurate and up-to-date patient records, ensuring compliance with all regulatory and organizational guidelines.
  • Quality Improvement: Participate in quality improvement initiatives to enhance patient outcomes and the overall effectiveness of the chronic care management program.

 

Qualifications 

  • Bachelor's degree in Nursing, Healthcare Administration, Social Work, or a related field. A Master's degree is preferred.
  • Current licensure as a Registered Nurse (RN), Licensed Practical Nurse (LPN), or relevant healthcare certification, depending on the state's requirements.
  • Currently enrolled or have completed a Nurse Practitioner (NP) program is preferred.
  • Proven experience in chronic care management or disease management programs.
  • Strong understanding of chronic health conditions, treatment guidelines, and evidence-based practices.
  • Excellent communication and interpersonal skills, with the ability to build rapport with patients and the healthcare team.
  • Empathetic and patient-centered approach to care, focusing on the unique needs and preferences of each patient.
  • Knowledge of electronic health record (EHR) systems and other healthcare-related technologies.
  • Ability to work collaboratively in a multidisciplinary healthcare team.
  • Strong organizational and time-management skills to manage multiple patient cases effectively.

Top of Form


Physical requirements 

  • Moves equipment weighing up to 50 pounds.
  • Moves throughout the building to meet with employees, patients, or visitors.
  • Must be able to remain in a stationary position during shift.
  • Ability to read, write, and speak English.
  • Frequent communication with patients about their experience at the health center. Must be able to exchange accurate information in these situations.
  • Operate a computer and other office equipment, such as tablets, scanners, printers, and phones.
  • Adhere to process protocol or procedures.

 

Details 

  • Schedule: Full-time exempt.
    • Hours Mon-Friday 8:00AM-5:00PM (as needed) (average 40 hours/week)
  • Location: Heartland Community Health Center & Heartland at Panda Pediatrics
    • Schedule may be altered by supervisor(s) as needed to allow for completion of expected duties of the position.

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