Chronic Care Management Coordinator

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River Oak Medical is looking for a Full-Time Chronic Care Management Coordinator. Pay is to be determined; depending on experience.

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. The Chronic Care Coordinator works in collaboration and continuous partnership with chronically ill patients and their family/caregiver(s), clinic providers and community resources in a team approach to increase patients’ ability for self-management and shared decision-making.

PRIMARY RESPONSIBILITIES:

· Can fulfill the clinic’s mission through quality healthcare to those in need while providing appropriate care for the whole person.

· 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 HER.

· 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/caregiver(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.

EDUCATION:

· Graduate of accredited CMA/RMA program, preferred

· Current CMA/RMA certification, preferred

EXPERIENCE:

· Minimum of 1-3 year work experience in a healthcare setting involving patients with complex chronic disease states preferred