What are the responsibilities and job description for the Chronic Care Management Specialist position at Eastern Shore Rural Health System?
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.