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Job Description

Job Summary:

As part of a team-based approach to care, the Clinical Care Manager (CCM) provides, coordinates, and organizes evidence-based care management to chronic disease patients, especially to those who are most at risk for health deterioration, sentinel events, and/or poor outcomes.

Essential Functions:

  • Responsible for assisting Primary Care Providers (PCPs) in coordinating and managing the care of vulnerable patients, ensuring that patients receive optimal care including acute illness and chronic disease management, education about lifestyle and behavior modification, and preventive care across multiple health settings with multiple providers
  • Manages care plans for patients admitted to and discharged from the hospital, patients seen the emergency room, and patients transitioning from or to any other health care facility with the objective of preventing further disease exacerbation, improving outcomes, increasing patient engagement in self-care, decreasing risk status, and minimizing hospital and ER utilization. 
  • Identifies, manages, and coordinates patient care and provides ongoing communication to the care team regarding patient care, patient needs, and plans of care
  • Provides direct patient care within the nursing scope of practice including, but not limited to, patient assessment, administration of vaccinations and medications, medication reconciliation, point-of-care testing, treatments, and lab and diagnostic test result review
  • Provide timely and informed patient triage
  • Involve patient support systems in care coordination, care planning, and in the education of patients and their families
  • Assist patients in building a patient action plan which includes self-management goal setting and a disease exacerbation prevention plan.
  • Utilizes behavioral strategies to assist patients in adopting healthy behaviors, improving self-care and managing chronic disease with a focus on educating and optimizing the member’s level of independence in navigating the healthcare system at all levels of the continuum.
  • Document patient care, ongoing evaluation, patient progress/risk status, care manager interventions, and a plan of care developed with the PCP, in the EHR in accordance with health center and nursing standards
  • Participate in quality, compliance, and regulatory standards
  • Participates in the orientation and mentoring of new clinical staff as expertise develops
  • Performs other duties as assigned

Education and Experience:

  • Registered Nurse License in MA
  • Bachelor’s degree in Nursing from an accredited college or university
  • 1-2 years of clinical experience
  • Current CPR certification