Chronic Care Coordinator
5 days ago
Job Summary:Under direction of the Nurse Manager of Clinical Services the Care Coordinator provides and facilitates communication of health information and performs clerical and clinical documentation and other support services for low acuity patients in the Chronic Care Management (CCM) program. He/She is responsible for triaging, coordination, documentation, communication, and tracking of low acuity CCM patient's calls, cases and records and assists in the development of care plans, conducts appointment scheduling, referral processing and medication management. The Care Coordinator engages patients and their families and/or representatives for disease management and education sessions to promote positive health and behavioral modifications. He/she provides information for basic social services, application assistance, and care planning to patients, as needed. Under the direction of the Nurse Manager of Clinical Services, he/she provides transition of care services to patients being discharged from post-acute settings; such as hospitals and skilled nursing facilities. He/she is responsible for ensuring billing and documentation is complete for chronic care management eligible patients.Essential Duties and Responsibilities:A general knowledge of primary care clinics, disease management and medical terminology is essential. Competency in prevention strategies and care planning for patients with comorbidities (chronic health conditions, behavioral health and substance abuse). Experience in care coordination, health education, patient engagement and social services is required. Knowledge of hospitals, specialists, and ancillary health services throughout the assigned community is preferred.Provides CCM services primarily to a panel of low acuity Traditional Medicare and Medicare Advantage plan patients who are assigned to his/her care by the Nurse Care Manager of Clinical Services and/or the RN Care Manager.Works in collaboration with the Nurse Care Manager of Clinical Services and patient's PCP to create and modify patient care plans and associated patient goals and instructions.•Assists patients with appointment scheduling, referral processing, prescription filling and performs other directions from the PCP and Nurse Manager of Clinical Services.•Interacts with respect and in a professional manner with patients, staff and external customers. Under direction of the Nurse Manager of Clinical Services, provides assistance and supplemental support for Transitional Care Management Nurse.Communicates with other health professionals, hospitals and community resources as the patient's advocate.Facilitates reminder calls for appointments, labs, diagnostics and outstanding quality improvement measures.Provides basic health education and disease management sessions to support positive behavioral change among CCM patients.Collaborates with hospitals, skilled nursing facilities and ancillary health services to support continuum of care. Reviews charts and requests outstanding information to ensure clinical documents from ER, urgent Care, hospitals skilled facilities and consult notes are on the patient's chart. Updates Care Team and medications lists. Assures that patient meets all quality measures, is taking medications and fulfilling orders for following up with specialists, completing labs and imaging as the provider directs for the patient's overall health and wellbeing.Documents the appropriate criteria for Chronic Care Management (CCM), Transitional Care Management (TCM), and behavioral health integration (BHI) for eligible patients and relays that information to the appropriate Care Management team member.Reviews care plans, patient charts, and other health information for the purposes of making acuity recommendations to the Nurse Manager of Clinical Services and/or the RN Care Manager.•Works with the Nurse Manager of Clinical Services and the Quality Improvement Manager and the MSRs to identify specific patient social and preventative care needs. Facilitates resolutions (when possible) with resources throughout an assigned geographic area.Completes telephonic campaigns for annual wellness visits, health risk assessments, and other quality improvement measures as assigned and directed.Participates in department rotating "on-call" schedule determined by the Nurse Manager of Clinical Services.Attends meetings for updates; as directed.Follows HIPAA and OSHA Standards.•Maintains HR compliance and procedures.•Ensures patient satisfaction by providing excellent service, putting Patients First Always.Education and Experience Requirements:Licensed Practical Nurse or Certified Medical Assistant (CMA) accreditation and a minimum of 2 years related care management or experience working in a primary care or post-acute setting is preferred or equivalent combination of education and experience to be determined by the Sr Director of Value Based CareKnowledge/Skills/Abilities:Experience in implementing and billing Chronic Care Management (CCM). Knowledge of legal and ethical standards for the delivery of primary care. Strong computer skills with knowledge of Microsoft Office products. Excellent verbal and written communication skills. Able to work independently and in a multidisciplinary team. Able to effectively utilize an electronic health record to document all patient encounters.
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