Chronic Care Management Coordinator

5 days ago


Russellville, Arkansas, United States Teche Action Clinic Full time
Job Summary

The Teche Action Clinic, a Federally Qualified Health Center, is seeking a qualified applicant for the Chronic Care Management Coordinator position in Franklin, Louisiana. This is a full-time position with office hours from Monday to Thursday, 7:30am to 5:30pm, and Friday, 8:00am to 12:00noon.

Job Duties and Responsibilities
  • Identify and assess the health care needs of adult and pediatric patients with complex illnesses, in collaboration with the primary care practice leadership team.
  • Develop and implement individualized care plans that integrate evidence-based clinical guidelines, preventive guidelines, and protocols.
  • Provide patient self-management support and empower patients to build capacity for self-care.
  • Coordinate patient care across settings and help patients and families understand healthcare options.
  • Monitor patient response to care plans and revise plans as needed.
  • Implement system of care to prevent and intervene early during acute exacerbations.
  • Collaborate with PCP, patient, and members of the healthcare team to ensure continuity of care.
  • Provide follow-up with patients and families during transitions from one setting to another.
  • Maintain required documentation for all care management activities.
  • Participate in Quality Assurance Performance Improvement (QAPI) Committee.
Requirements
  • License Practical Nurse or Master of Social Work License preferred.
  • Two years of experience in adult medicine and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical setting, within the past five years.
  • Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education.
  • Critical thinking skills and ability to analyze complex data sets.
  • Excellent assessment and triage skills.
  • Excellent communication and interpersonal skills.
Preferred Qualifications
  • Care management experience.
  • Experience as participant in continuous quality improvement.
  • Completion of self-management support training.

Due to CMS Mandate, all applicants must be fully vaccinated prior to onboarding with TAC, with the exception of an approved Medical or Religious Exemption.



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