Chronic Care Management Coordinator

SWLA CENTER FOR HEALTH SERVICES

JOB DESCRIPTION

JOB TITLE: Chronic Care Management Coordinator

DEPARTMENT: Nursing

SITE: Lafayette (System- wide Collaboration)

SUPERVISED BY: CNO

STATUS: Full-Time/ Exempt

SUMMARY:

The Chronic Care Management Coordinator works with patients referred for assistance in accessing and utilizing health care resources due to their complex chronic illnesses. This position supports improvements in health outcomes through coordinating care, educating patients, building trust between patients and medical practitioners, and enhancing communication and the continuity of care. As a member of an interdisciplinary team, this position will consult with other healthcare team members to coordinate the provision of patient education, preventive care and disease management. Integrates evidence-based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care. Provides targeted interventions to avoid hospitalization and emergency room visits. Coordinates care across settings and helps patient/families understand health care options. Provides other duties as assigned by the CNO.

This task involves monitoring project plans, schedules, work hours, expenditures, organizing and participating in stakeholder meetings, providing administrative support, and ensuring that project deadlines are met in a timely manner.

QUALIFICATIONS AND SKILLS:

Basic requirements: - ADN, BSN, Degree in Nursing 3-5 years' work experience related to chronic disease management and active licensure as an RN in Louisiana / Experience working in clinical/ community out-patient settings, Experience working with diverse population groups, Content knowledge and expertise in program-specific field

To be successful, you will need to be a self-starter, flexible, adjust to rapid change, anticipate and meet the needs of stakeholders, exhibit a positive attitude and enthusiasm to support stakeholders in executing all tasks required to meet project goals. The successful Coordinator can work on tight deadlines, is competent in using Microsoft Office applications such as Word, PowerPoint, Outlook, and Excel, and has exceptional verbal, written, emotional intelligence, and presentation skills to adjust various learning styles.

1. Experience as participant in continuous quality improvement (preferred)
2. Completion of self-management support training (preferred)
3. Excellent assessment and triage skills. Ability to implement evidence- based interventions and protocols for chronic conditions.
4. Demonstrates excellent communication - both verbal and written.

1. Assist CHO, CNO, COO and members of the interdisciplinary team to monitor clinical outcomes and provide evidence-based strategies for reporting and monitoring data outcomes
2. Assist and manage implementation/ project management for HTN, DM under the direction of the CNO
3. Knowledgeable in group dynamics, presentation, and facilitation skills
4. Manages a comprehensive case management program and utilizes data to assist with meeting target and strategic goals of the Senior Leadership Team
5. Familiarity with local community resources for patients with chronic disease.
6. Knowledge of patient teaching, health promotion and disease prevention methods related to routine health care and those designed to address the needs of patients with chronic, disabling health conditions.
7. Understands the purpose of and has a working knowledge of PCMH concepts
8. Ability to maintain effective work relationships
9. Ability to make accurate professional judgments
10. Ability to develop a collaborative therapeutic alliance with individuals.

1. Assess cognitive/verbal skills and identifying barriers to accessing healthcare.
2. Provide individual and family educational interventions including self-management goal setting, counseling and training on the habits, lifestyle changes, supplies and tools necessary to manage their disease.
3. Perform individualized assessment of a patient's educational needs and provide tools to aid in managing their disease(s) effectively.
4. Provide individual counseling on office procedures, eligibility for programs/services, importance of a primary care medical home and other health issues.
5. Monitor patients for changes in health status after initiation of a new medication, a hospitalization or recent decline in function.
6. Follow-up with patients when barriers to referrals are identified.
7. Monitor lifestyle factors affecting health - such as tobacco use, substance abuse, nutrition and physical activity - and assist the patient with goal setting to achieve behavioral change.
8. Document assessments, education, goals, outcomes and updates in the patient's EHR for review by their practitioner.
9. Participate in staff meetings focused on coordinating patient care. Understands orders, laboratory testing, immunizations, COVID testing and referrals for preventive health needs as indicated per disease management protocols.
10. Provide counseling and facilitate screening for COVID community events as indicated. Participates in Outreach community education as it relates to public health demands and mission of the organization
11. Teach individual and/or group classes covering topics which build skills in self-management of one or more chronic diseases
12. Assist in the development and maintenance of a library of educational resources including written materials, web/online based and DVDs on related health issues. Serve as a consultant to the rest of the health care team for educational resources, reviewing them for language, cultural competency and reading level.

1. Demonstrate the Mission and act in ways that advance the best interest of the customers entrusted to our care. Positively represents SWLA Center for Health Services (SWLA) in the workplace and the community
2. Present a professional image: apparel and appearance are appropriate according to SWLA department dress code
3. Demonstrate effective communication and listen attentively to customers and promptly act upon requests with consideration for patient privacy. Keep customers informed about their care and treatment in a comfortable atmosphere
4. Respect the gifts and talents (the diversity that co-workers bring to their jobs) of each other. Demonstrates effective communication and assists co-workers as necessary
5. Respect the privacy and confidentiality of the customers we serve, providers, co-workers and the community
6. Practices safe work habits and maintain a safe environment for self, co-workers, patients, and visitors
7. Work collaboratively to solve problems, improve processes, and develop services. Acts as an advocate for our customers
8. Complies with organization/department policies and procedures, including, but not limited to confidentiality, safety, cooperation/flexibility and attendance
9. Understands and complies with applicable federal/state laws and Standards of Conduct as related to assigned job duties
10. Participates in departmental and organizational quality improvement efforts