CHRONIC CARE MANAGEMENT and ANNUAL WELLNESS COORDINATOR NEEDED

SUMMARY OF DUTIES: The Chronic Care Coordinator performs care management for chronically ill patients with chronic diseases such as chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, and/or congestive heart failure. Also conducts AWV in an effort to bridge the gaps in care, and provide a successful long-term care plan. Please only apply if you have the below required experience.

PRIMARY RESPONSIBILITIES:

• CCM Coordination:

· Responsible for registry of chronic care management (CCM) patients.

· Validates enrollment of CCM patients based on provider request

· Conducts minimum of one 20 minute of telephone or in-person counseling and education per month to each CCM patient on roster.

· Complies with documentation requirements of the Chronic Care Management program by carrying out the care plan with the patient, family/caregiver(s) and providers and recording in the EHR.

· Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, and facilitates changes as needed.

· Creates an ongoing process for patient and family/caregivers(s) to determine and request the level of care coordination support they desire.

· Facilitates patient access to appropriate medical and specialty providers.

· Coordinates transition of inpatient to outpatient care in an effort to decrease readmission rates

· Work closely with in-office providers to manage the day to day calls involving: symptom control, medication management, and provide patient and family education

· Educates patient and family/caregiver(s) about relevant community resources.

· Assist with the identification of “high-risk” patients (the chronically ill and those with special health care needs), and assist on the enrollment of these to the patient registry.

· Coordinates continuity of patient care with external healthcare organizations and facilities including from the primary care provider to a specialty care provider.

· Supports patient self-management of disease and behavior modification interventions.

· Provides patient health counseling, education and instruction.

• AWV Coordination

Review clinic schedule and identifies patients appropriate and due for Medicare AWV.

Work collaboratively with clinical teams to accomplish AWV in an efficient manner for patient and team.

Follow AWV protocols and standing orders including completion of preventive services that may result from AWV.

Develop knowledge of Medicare preventive services and clinical guideline recommendations for those services.

Address open quality gaps with patients and works collaboratively with patient towards closure of those gaps.

Appropriately documents within the electronic record to satisfy closed quality gaps.

May assist with other clinical duties such as prior authorizations, patient messages, prescription refills.

Utilize appropriate protocols and standing orders in delivering patient care.

Participate in regular team meetings, huddles, staff meetings and quality improvement projects to improve patient care.

Consult with the clinical staff and ancillary department staff to eliminate barriers to the efficient delivery of care. Identify service delivery problems and potential for effective patient management intervention.

Maintain annual competencies for role.

Document all communication with patient in electronic medical record.

Perform all other duties as assigned.

EDUCATION:

· Graduate from accredited LPN or MA school

· Current LPN license for the state of Georgia, or MA certification

EXPERIENCE:

· Minimum of 1-3 year work experience in a healthcare setting involving patients with complex chronic disease states preferred. Conducting, documenting, and billing AWV.

SKILLS:

• Strong working knowledge of chronic disease states including chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, and congestive heart failure and basic medical management of these states
• Must be highly motivated, result-oriented with strong skills in presenting, communicating, organizing, multi-tasking and time management skills
• Strong organizational and interpersonal skills
• Excellent customer service skills demonstrated by positive feedback from patients/team.
• Ability to identify problems and recommend solutions
• Ability to read, write and communicate effectively orally and in writing
• Basic computer skills including previous work with an electronic health record (EHR)
• Ability to work independently

ENVIRONMENTAL/ WORKING CONDITIONS:

Combination of medical office and exam / procedure room setting which is a well-lit, well-ventilated, adequate space.

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.

Job Type: Full-time

Pay: $18.00 - $21.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Experience:

• chronic care management: 2 years (Required)
• Annual Wellness Visits: 2 years (Required)
• EMR: 2 years (Preferred)

License/Certification:

• Certified Medical Assistant (Required)

Work Location: In person

Salary : $18 - $21