Chronic Care Management Specialist

The Chronic Care Management Program is a Medicare program aimed at managing patients with multiple (2 or more) chronic conditions that are expected to last at least 12 months.

The Chronic Care Management Specialist works with providers, patients, and insurance companies to help ensure enrolled patients receive the highest level of care, assisting them with their chronic care and preventative care needs to help reduce long-term health concerns and hospitalizations. They educate patients on the benefits of recommended preventative care services and build rapport with them to improve patient engagement, self-care management, and adherence to their individualized plan of care. They track patients’ chronic care needs and work with teams within the organization to identify barriers for patients accessing care and link them to community resources. They act as a liaison, collaborating with our community partners and other healthcare organizations to ensure continuity of care and care coordination activity within the EMR.

• LPN/RN license with clinical experience required.
• Clinical experience with an understanding of chronic disease management and knowledge of all life cycles required.
• Knowledge of Microsoft Excel is required.
• Individual must be professional, self-motivated and have strong attention to detail, communication, teamwork, customer service and computer skills.
• Must complete and maintain all recertification requirements for continued licensure and/or certification and retain updated copies as applicable.
• Must maintain Basic Life Support (BLS) certification for all life cycles.
• Must demonstrate excellent internal and external customer service skills.
• Certification as an Interpreter is preferred and ability to provide bilingual patient care is a plus.
• Must have a valid driver's license and reliable transportation.

• Generate a minimum of 340 billable encounters monthly (average 17 per day) in support of the Chronic Care Management (CCM) program.
• Identify and scan schedules for CCM eligible patients for enrollment and promote the program at the point-of-care based on patient volume.
• Complete CCM enrollments and conduct required monthly phone calls in accordance with Centers for Medicare & Medicaid Services (CMS) guidelines.
• Ensure all required documentation elements are completed to support CCM services and associated Annual Wellness Visit (AWV) component billing.
• Assist in closing healthcare gaps to improve Uniform Data System (UDS) and Healthcare Effectiveness Data and Information Set (HEDIS) quality measures aligned with health system goals.
• Access electronic medical records (EMR) from referral sources to obtain diagnostic and laboratory results and update the patient’s EMR accordingly.
• Act as a liaison to community partners, capturing care coordination activities within the EMR while effectively communicating with hospital case management teams and local skilled nursing facility personnel to address specific patient care needs.
• Perform other duties and tasks as directed by the Chronic Care Management Coordinator.
• Assess barriers to care, and coordinate services to improve patient engagement and self-care management, including, but not limited to medication adherence/management.
• In collaboration with the Case Management Specialist (CMS), monitor emergency department and hospital discharge reports to identify high-risk and focused-population patients, utilizing appropriate triage protocols to assist in care coordination.
• In collaboration with CMS, initiate and support transitions-of-care visits to ensure continuity and reduce readmissions.
• In collaboration with the Health Education Team, schedule and Annual Wellness Visits (AWV) and Initial Preventive Physical Exams (IPPE).
• In collaboration with CMS, promote and support participation in the comprehensive advanced care planning program.