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Chronic Care Management Coordinator
2 months ago
At SWLA Center for Health Services, we are seeking a highly skilled and compassionate Chronic Care Management Coordinator to join our team. As a key member of our healthcare team, you will play a vital role in coordinating care for patients with complex chronic illnesses, ensuring they receive the best possible outcomes.
Job Summary:The Chronic Care Management Coordinator will work closely with patients, healthcare providers, and community resources to develop and implement individualized care plans that address the unique needs of each patient. This role requires strong communication and interpersonal skills, as well as the ability to work effectively in a fast-paced environment.
Key Responsibilities:- Assess patients' cognitive and verbal skills, identifying barriers to accessing healthcare and developing strategies to overcome them.
- Provide individual and family educational interventions, including self-management goal setting, counseling, and training on habits, lifestyle changes, supplies, and tools necessary to manage chronic diseases effectively.
- Perform individualized assessments of patients' educational needs and provide tools to aid in managing their diseases effectively.
- Monitor patients for changes in health status after initiation of new medications, hospitalizations, or recent declines in function.
- Follow up with patients when barriers to referrals are identified.
- Monitor lifestyle factors affecting health, such as tobacco use, substance abuse, nutrition, and physical activity, and assist patients with goal setting to achieve behavioral change.
- Document assessments, education, goals, outcomes, and updates in patients' electronic health records for review by their practitioners.
- Participate in staff meetings focused on coordinating patient care, understanding orders, laboratory testing, immunizations, COVID testing, and referrals for preventive health needs as indicated per disease management protocols.
- Provide counseling and facilitate screening for COVID community events as indicated, participating in outreach community education as it relates to public health demands and the mission of the organization.
- Teach individual and/or group classes covering topics that build skills in self-management of one or more chronic diseases.
- Assist in the development and maintenance of a library of educational resources, including written materials, web-based resources, and DVDs on related health issues, serving as a consultant to the rest of the healthcare team for educational resources, reviewing them for language, cultural competency, and reading level.
- ADN, BSN, or degree in nursing with 3-5 years' work experience related to chronic disease management and active licensure as an RN in Louisiana.
- Experience working in clinical/community outpatient settings and with diverse population groups.
- Content knowledge and expertise in program-specific fields.
- Self-starter with flexibility, ability to adjust to rapid change, and anticipate and meet the needs of stakeholders.
- Positive attitude and enthusiasm to support stakeholders in executing all tasks required to meet project goals.
- Competent in using Microsoft Office applications, including Word, PowerPoint, Outlook, and Excel.
- Exceptional verbal, written, emotional intelligence, and presentation skills to adjust various learning styles.
- Experience as a participant in continuous quality improvement.
- Completion of self-management support training.
- Excellent assessment and triage skills, ability to implement evidence-based interventions and protocols for chronic conditions.
At SWLA Center for Health Services, we offer a dynamic and supportive work environment, competitive compensation and benefits package, and opportunities for professional growth and development. If you are a motivated and compassionate individual who is passionate about delivering high-quality patient care, we encourage you to apply for this exciting opportunity.
