Chronic Care Nurse

23 hours ago

Roseburg, United States Evergreen Family Medicine, PC Full time
Evergreen Family Medicine is committed to providing excellent care for your family with clinics in Roseburg, Sutherlin and Myrtle Creek Oregon. Evergreen Family Medicine serves outpatient needs, including Urgent Care, Family Practice, Women’s Health, Occupational Health, and school-based telehealth.

Evergreen Family Medicine is a Drug Free Workplace. All candidates that are offered employment will be required to pass a pre-employment drug screen and background check.

The Chronic Care Manager provides chronic care/clinical case management services aimed at enhancing patient-centered care and maximizing outcomes across the patient care continuum. Case management services include patient advocacy, monitoring patient care to ensure progress toward desired outcome, addressing patient and family needs, resolving obstacles to effective care, and implementing disease modifying interventions.

Responsibilities and Duties:

  • Maintains confidentiality according to HIPPA regulations and EFM policies 
  • Adheres strictly to EFM departmental standards and policies, including state and federal regulations. 
  • Communicates effectively and professionally with coworkers, managers, and patients via phone, email, or in person. 
  • Coordinates the case management process from the patient’s admission to discharge and follow-up care, including ER follow up care. 
  • Capable of assessment of physical functioning as well as an understanding of both acute and chronic illness and disability. 
  • Identifies patients who are suitable for chronic acre/case management intervention. Seeks authorization for chronic care/case management services for families. 
  • Assess needs of patients/family, coordinates care and resources. Plans, develops, and implements appropriate patient care goals.
  •  Familiarity with community support services and resources. Knowledge of relationships among medical, psychological, and behavioral components of illness/injury. 
  • Monitors and documents quality of care to ensure patient care plan goals and appropriate and understood as well as implemented. Identifies patient needs, including those of ethical and cultural nature and assures that they are addressed. 
  • Assists with finding resources that can help with funding for medications and insurance issues. 
  • Identifies delays in service request or treatments and communicates them to the healthcare team. 
  • Establishes measurable chronic acre/case management goals that promote cost-effective, high quality outcomes. 
  • Provides and/or assists in diabetic education, smoking cessation, and wound care management. 
  • Visits patients in care facilities and performs Chronic Care Management Services
  •  Performs other duties as assigned. 
 Qualifications and Skills:


  • High School Diploma or equivalent
  • Degree, license or certification in appropriate field of study with two years of professional experience in a clinically related area.
  • Communication, interpersonal, clerical, and organizational skills necessary to complete job duties. 
  • Ability to handle the confidential aspects of the work. 
  • The ability to type at least 40 wmp and activate/operate computers and office equipment.
Physical requirements:

  • Prolonged periods sitting at a desk and working on a computer. 
  • The employee is frequently required to walk; use hands and fingers, handle, or feel; and reach forward with hands and arms. 
  • The employee is occasionally required to sit and stoop, kneel, or crouch. 
  • May be exposed to patients with infectious diseases. 
  • Must be able to lift up to 35 pounds at times. 
Our culture and values are every employee’s responsibility: The needs of our patient come first S.P.I.R.I.T 

  • Stewardship 
  • Patient & Population Focused Health Care 
  • Integrity 
  • Respect
  • Innovation 
  • Teamwork 

Benefits: 


  • Health, Dental, Vision benefits 
  • Life Insurance 401k with a company match up to 6% 
  • Paid Time Off 

Compensation:  Dependent on licensure and experience 

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