Chronic Care Manager

SUMMARY OF DUTIES:

• The Care Manager performs care management support services for seriously ill patients suffering from chronic diseases such as chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, behavioral health, and substance abuse disorders. The Care Manager works in collaboration and partnership with chronically ill patients and their family/caregiver(s), clinic providers and community resource providers using in a team approach to increase patients’ ability for self-management and shared decision-making. This position requires a strong background in nursing and medical terminology. The ideal candidate will possess excellent case management skills and be familiar working with high-risk patients.

PRIMARY RESPONSIBILITIES:

• Fulfills Freedmen Medicine’s mission to enhance patient’s lives through quality healthcare to those in need while providing appropriate physical, mental, and emotional care for the whole person.
• Acknowledges acceptance of identified patient load and advocates for their patients and communicates with other healthcare providers to accurately update documents and schedule appointments.
• Validates enrollment of chronically ill patients based on provider requests.
• Coordinates continuity of patient care with primary care providers, specialty care providers and community resources to affect positive health outcomes in an effort to decrease readmission rates.
• Conducts minimum of one 40-minute session of telephone or in-person counseling and education per month to each care management patient on roster and ensures compliance with established time frames for specific services and functions.
• Complies with documentation requirements of the Care Management program by carrying out the care plan with the patient, family/caregiver (s) and providers and records results in the electronic Health Record (HER) and other related systems.
• Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, facilitates changes as needed, and ensures the Care Management supervisor is aware of significant changes in patient’s condition and disposition.
• Work closely with community resources and providers to manage the patient’s day to day needs involving: symptom control, medication management, and provide patient and family education.
• Provides patient health counseling, education and instruction and educates patient and family/caregiver(s) about relevant community resources.
• Supports patient self-management of disease and behavior modification interventions.
• Provide weekly updates to Care Management Supervisor on adherence to identified key performance indicators and supporting metrics and communicates plan to mitigate performance issues.

EXPERIENCE:

• Two years nursing experience

This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.