What are the responsibilities and job description for the Chronic Care Management Nurse (Dallas TX) position at Daiya Healthcare?
Position Overview:
Daiya Healthcare is seeking a dedicated and skilled Chronic Care Management (CCM) Nurse to join our team in the post-acute care setting. The ideal candidate will work collaboratively with other medical professionals to manage the health and well-being of our patients, particularly those with chronic diseases, recent hospitalizations, or emergency department discharges. The CCM Nurse will play a crucial role in care coordination, patient education, quality improvement initiatives, and tracking and trending patient ACO metrics.
Key Responsibilities:
1. Assist in care coordination for patients with chronic diseases, recent hospitalizations, or emergency department discharges
2. Utilize motivational interviewing techniques to discuss services with patients based on standing orders and quality measures guidelines
3. Follow up on previous orders and consult with primary care providers as needed
4. Document data from new patient records and specialist reports, updating medical, social, and surgical history from consults, emergency department, and hospital reports
5. Ensure appropriate follow-up to close care gaps and enter data in discrete and appropriate fields
6. Collaborate with vendors and external partners to download and upload beneficiary utilization and quality data on a monthly basis
7. Track and trend patient ACO metrics, including Annual Wellness, diabetes, Return to Hospital, hypertension, and depression
8. Assist providers in improving metrics by monitoring patient charts and chronic condition indicators
9. Manage the Chronic Care Management process on-site
10. Perform administrative duties, including typing, mail processing, ordering supplies, answering phone calls, and scheduling meetings
11. Demonstrate excellent written and oral communication skills, as well as strong organizational and analytical abilities
12. Assist with other duties as requested
Experience Requirements:
- Minimum of 2 years of clinical experience as an LPN
-Experience in a SNF (Preferred)
-Chronic Care Management Experience (Preferred)
Education Requirements:
- High School Diploma or equivalent (required)
- Graduate of an accredited LPN Program (required)
Licensure/Certification Requirements:
- Texas LPN license (required)
Work Schedule:
- Monday through Friday
- No weekends or call requirements
-Travel required to several facilities in the Dallas/ Forth Worth area.
At Daiya Healthcare, we are committed to providing exceptional care to our patients in the post-acute setting. Join our team and make a difference in the lives of those we serve. We offer a supportive work environment, opportunities for growth, and competitive compensation and benefits.
Job Type: Full-time
Pay: $28.50 per hour
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Paid time off
- Vision insurance
Work Location: Hybrid remote in Plano, TX 75093
Salary : $29