Description

Is it your passion to help patients improve their health and manage their chronic conditions? As our practice continues to grow, we have a need for additional staff to engage our complex patients with multiple chronic conditions between office visits to help them stay on track.

The Chronic Care Management Specialist is responsible for overseeing the care of patients with chronic illnesses, collaborating with healthcare providers, and implementing care plans to optimize patient health and well-being. The candidate will serve approximately 350 patients at the clinic(s) assigned.

The Specialist must have one of the following: 

- LPN Licensure strongly preferred

- Nationally recognized Medical Assistant (MA) certification or Licensed Practical Nurse (LPN) certification. 

- EMT-B, EMT-I, or EMT-P License from NREMT or GA State Board of EMS. 

*Certifications will need to be provided prior to hiring.

Requirements

• Duties:
• Conduct comprehensive assessments of patients with chronic illness to understand their medical history, current health status, and healthcare needs.
• Develop individualized care plans in collaboration with patients, their families, and healthcare providers. The care plan must be shared with the overseeing provider.
• Set goals and objectives for managing chronic conditions and improving overall health.
• Coordinate and facilitate communication among healthcare providers, specialists, and support services to ensure a seamless continuum of care.
• Monitor and track patient progress, adjusting care plans as needed.
• Provide education to patients and their families about their chronic conditions, treatment options, medication, and lifestyle modifications.
• Empower patients to actively participate in their own care and self-management
• Connect patients with community resources, support groups, and other services that can enhance their overall well-being
• Assist with navigating insurance coverage and financial assistance programs.
• Maintain accurate and up-to-date patient records, including electronic health records (EHRs) to ensure continuity of care and compliance with regulations.
• Collaborate with interdisciplinary healthcare teams, including physicians, nurses, social workers and other healthcare professionals, to optimize patient outcomes.
• Participate in quality improvement initiatives to enhance the effectiveness and efficiency of chronic care management services.
• Timely and proper communications with healthcare providers of any urgent health-related needs, medication refills, and appointment requests communicated by the patient.
• Respects patient confidentiality at all times and treats patients with courtesy and respect.

Required Skills:

• Outstanding communication skills, both written and verbal.
• Strong interpersonal skills.
• Relevant clinical experience, particularly in chronic care management.
• Familiar with relevant regulations and compliance standards.
• Computer skills including data entry functions, the use of Allscripts or other various EHRs, and various software programs.
• Time management skills.
• Thrive in a team environment with the ability to establish and maintain effective working relationships with patients, caregivers, fellow team members, and healthcare professionals.
• Self-motivated.
• Ability to organize and manage competing priorities.
• Ability to problem solve and show good judgment.
• Knowledge of medical terminology.
• Ability to react calmly and effectively in emergency situations.
• Minimum requirement of a high school diploma or GED equivalent.

Preferred, not required, skills:

Proven work experience as a care manager or similar role.