Chronic Care Management Specialist

2 weeks ago

Layton, Utah, United States Tanner Memorial Clinic Full time
Job Overview

Tanner Memorial Clinic is seeking a dedicated Chronic Care Coordinator to enhance patient care and support individuals with chronic conditions.

Location: Layton

Employment Type: Full-Time

Key Responsibilities:
  • Analyze patient information using population health tools and Electronic Health Record (EHR) systems to identify and enroll high-risk patients in care management programs.
  • Collaborate with primary care providers and patients to create comprehensive, goal-oriented care plans.
  • Utilize clinical expertise to address chronic disease management, psychosocial factors, behavioral health, and barriers related to hospital usage, medications, and social determinants of health.
  • Facilitate care coordination by acting as an advocate and resource for patients, their families, and healthcare providers, fostering strong relationships within the community.
  • Ensure compliance with billing protocols and document care plans accurately, gaining proficiency in various EHR systems.
  • Employ ACO methodologies and care management resources to provide telephone support to patients, promoting self-management and improving health outcomes.
  • Recognize when patients have met their goals and manage their dis-enrollment from programs.
  • Work alongside ACO team members and care management specialists to align initiatives and address care management challenges through a collaborative approach.
  • Design and conduct training sessions for care managers on population health tools and effective care management strategies.
  • Contribute to the development of enhanced ACO systems and workflows to meet the needs of care managers and patients efficiently.
  • Perform aspects of the Medicare Annual Wellness Visit as needed, including screenings and preventive services.
  • Engage in additional ACO-related activities as required.
Qualifications:

Education:

  • Preferred: Medical Assistant (MA) or Certified Nursing Assistant (CNA)

Experience:

  • Preferred: Medical Assistant with relevant skills and knowledge.
  • 2-5 years of experience in case management, public health, utilization management, or care coordination across various settings.
  • Familiarity with patient activation, motivational interviewing, and chronic disease self-management is advantageous.
  • Proficient computer skills and a willingness to learn new software applications, including EHR and population health management tools.
  • Experience working with vulnerable populations and understanding value-based healthcare principles.
  • Exceptional written and verbal communication skills, with the ability to influence others positively.
  • Strong work ethic emphasizing productivity, collaboration, and teamwork.
  • Ability to manage multiple tasks with minimal supervision.
  • Knowledge of continuous quality improvement practices.
Performance Expectations:

Knowledge:

  • Clinical Knowledge: Understanding of chronic diseases and their psychosocial aspects.
  • Population Health Management: Skilled in using tools and EHR systems for patient data analysis.
  • Care Coordination: Expertise in care coordination principles and community relationship building.
  • ACO Methodology: Familiarity with ACO practices and care management support.
  • Medicare Annual Wellness Visit: Competence in conducting wellness visit components.

Skills:

  • Communication: Strong written and oral communication abilities.
  • Computer Proficiency: Excellent skills with a readiness to learn new applications.
  • Training and Education: Capable of developing and delivering training on care management practices.
  • Teamwork: Committed to collaboration and productivity.
  • Project Management: Proficient in managing multiple projects efficiently.

Abilities:

  • Patient-Centered Approach: Focus on addressing the holistic needs of patients.
  • Problem Solving: Ability to identify and resolve care management barriers.
  • Continuous Quality Improvement: Knowledge of techniques to enhance care services.
  • Adaptability: Willingness to adjust to changes in healthcare practices and technologies.

Work Environment: Office setting

Mental/Physical Requirements: Primarily sedentary work involving computer use.

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