Chronic Care Management - CMA or LPN

Job Title: CMA or LPN - Chronic Care Management

Job Category: Clinical

Home Location: Thomasville

Travel Required: Varies

Level/Salary Range: Competitive based on Experience

Position Type: Non-Exempt

Reports to: Chronic Care Manager

Job Summary

The Chronic Care Management CMA/LPN is part of our patient Care Team. The CCM CMA/LPN’s primary responsibility is to provide telephone chronic conditions care management for the patient or caregiver of Primary Care of Southwest Georgia. Responsibilities include, but are not limited to, triaging, coordinating, documenting, communicating, and tracking of CCM patient calls, cases and records. The goal of the CCM CMA/LPN is to facilitate care between provider visits in order to obtain the patient’s best outcome, prevent complications, prevent hospital readmission, and/or prevent repeated emergency room visits.

Duties/Responsibilities

• Initiate phone calls to patient or assigned caregiver at least monthly to manage/monitor care with the sum of the monthly interactions to accumulate no less than 20 minutes per patient per calendar month
• Assess client’s needs for services and cooperatively develop an integrated patient centered care plan and goals with the patient/family and other providers.
• Assist with ongoing patient needs and manage internal/external referrals to other providers
• Assist patient and family for entitlements and other community services, including transportation
• Work collaboratively with the Care Team and other facility members to provide outreach and engagement
• Work closely with providers and care team to manage incoming calls involving symptom control, medication management, and appointment scheduling
• Provide patient and/or family with clear instructions and education on chronic conditions
• Act as the main point of contact for the patient and ensure coordination, follow-up, and continued engagement with the Care Team.
• Educate the patient on contacting PCSG for non-emergent concerns and when to contact 911
• Respond to incoming calls/voicemails and conduct outgoing calls between recurring visits to identify and proactively address emerging issues.
• Contact and assess patients following an ER or inpatient hospital visit, coordinate transitional care, and facilitate follow-up with PCP.
• Ensure and direct patients to keep follow-up appointments while assessing met CDSS measures
• Establish, retain, and grow strong relationships with patients
• Communicate with other health care providers regarding patient’s status
• Utilize resources to meet the needs of the patient and/or caregiver
• Provide written and verbal educational material regarding patient’s chronic conditions, treatment, medication, and care plans
• Participate in continuing education and in-service programs
• Maintain strict confidentiality following HIPAA regulations
• Other duties as assigned or modified

Competencies

• Excellent work ethic
• Self-motivated and self-directed
• Professional demonstration promoting values of PCSG
• Excellent verbal and interpersonal communication skills
• Clinically strong knowledge of chronic diseases
• Excellent customer service skills

Required Skills & Abilities

• Georgia CMA Certification or LPN license (Required)
• BLS Certified (Required)
• 2 years of recent clinical experience preferred

Physical Demands

• Prolonged periods of sitting at a desk and working on a computer.
• Ability to lift at least twenty pounds at times.

Job Type: Full-time

Benefits:

• Dental insurance
• Disability insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance

Experience:

• Medical/Clinical: 2 years (Preferred)

License/Certification:

• BLS Certification (Required)

Work Location: In person

Salary : $51,579 - $66,727