Position Overview: As a Chronic Care Management Nurse, you will play a crucial role in providing comprehensive healthcare support to patients with chronic conditions. Your primary responsibility will be to coordinate and manage the ongoing care and treatment of patients with complex and long-term medical conditions, ensuring they receive high-quality and personalized care. You will work closely with interdisciplinary healthcare teams, patients, and their families to optimize outcomes and promote overall wellness.

Key Responsibilities:

1. Chronic Care Coordination: Collaborate with healthcare professionals, including physicians, specialists, and care teams, to develop and implement individualized care plans for patients with chronic conditions. Coordinate and manage the delivery of healthcare services, ensuring seamless transitions between different healthcare settings.

2. Patient Assessment and Monitoring: Conduct thorough assessments of patients' medical history, symptoms, and current health status. Regularly monitor and evaluate patients' progress, identifying any changes or complications in their condition. Utilize evidence-based guidelines and protocols to guide decision-making and optimize patient outcomes.

3. Care Plan Development: Develop comprehensive care plans that address patients' physical, emotional, and psychosocial needs. Include appropriate interventions, medications, lifestyle modifications, and self-care strategies. Ensure that care plans and reportable outcomes are individualized, patient-centered, and promote continuity of care.

4. Patient Education and Support: Provide patient education on disease management, medication adherence, self-care practices, and lifestyle modifications. Empower patients to actively participate in their healthcare by promoting health literacy and self-management skills. Offer emotional support, address concerns, and provide resources for patients and their families.

5. Care Coordination and Communication: Work with care coordinators to serve as a central point of contact for patients, their families, and healthcare providers. Facilitate effective communication and information exchange between all involved parties. Work with Care Coordination team to coordinate

appointments, referrals, laboratory tests, and diagnostic procedures to ensure timely and efficient healthcare delivery.

6. Documentation and Compliance: Create care plans that specifically address medical chronic conditions and create reportable outcomes. Maintain accurate and up-to-date patient records, documenting all assessments, interventions, and communications. Adhere to regulatory guidelines, ethical standards, and organizational policies. Ensure compliance with privacy regulations, such as HIPAA, to protect patient confidentiality.

7. Quality Improvement: Participate in quality improvement initiatives, data collection, and outcome measurement related to chronic care management. Contribute to the development and implementation of evidence-based practices and protocols to enhance patient care and outcomes.

Job Type: Full-time

Pay: $24.50 - $28.50 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Employee discount
• Flexible schedule
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Parental leave
• Retirement plan
• Tuition reimbursement
• Vision insurance

Medical specialties:

• Addiction Medicine
• Emergency Medicine
• Geriatrics
• Internal Medicine
• Ob/Gyn
• Pediatrics
• Podiatry
• Primary Care
• Psychiatry
• Sports Medicine

Physical setting:

• Outpatient

Standard shift:

• Day shift

Weekly schedule:

• Monday to Friday

Ability to Relocate:

• Dunkirk, NY 14048: Relocate before starting work (Required)

Work Location: In person