Chronic Care Manager

Description

POSITION SUMMARY:

The Chronic Care Manager RN works to eliminate barriers to care for (primarily) high risk patients to reduce the risks of admission or readmissions, and ER visits at hospitals. The CCM Manager will work as part of the care team with Providers, Clinic Manager, and Billing to help improve the health, wellbeing, and satisfaction of our patients with chronic and complex diseases. This includes managing high risk patients to improve patient compliance clinical guidelines; educate patients and their families on their specific disease processes, and provide ongoing assessment, monitoring, and re-evaluation of health-related needs. Provide leadership and guidance to the chronic care team to ensure compliance with relevant healthcare regulations and that quality care is delivered in a timely manner.

RESPONSIBILITIES:

· Monitor and evaluate the quality of care provided by the chronic care management team.

· Implement and oversee quality improvement initiatives to enhance patient outcomes.

· standards

· Collaborate with other healthcare professionals, including physicians and nurse practitioners to ensure comprehensive and coordinated care.

· Clinical documentation of acute and chronic healthcare issues, symptoms, and care goals through patient encounters in the EMR system

· Documentation must be appropriate, thorough, and completed promptly.

· Ensure all appropriate consent forms are signed and dated.

· Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with care providers.

· Has knowledge of common chronic medical conditions presented in the population served and is able to: educate the patient on their medication conditions and medications and build their self-management skills.

· Delegate assignments to CCM team, follow up on completion, and be consistently available for timely consultation regarding patient matters.

· Other duties as assigned.

Requirements

QUALIFICATIONS:

· Exempt, Licensed, Full-Time position.

· Bachelor of Science degree in nursing or work-related experience.

· Must be licensed in Maryland as a Registered Nurse

· Must have demonstrated solid interpersonal, communication, and management skills.

· Must be able to continually update clinical knowledge and skills through formal and informal education and review of current literature.

· Must have knowledge of ambulatory and clinical practices, workflows, and operations.

· Must work well independently, have sound decision making skills, and work effectively with and through inter-professional colleagues when required to make and facilitate complex decisions.

· Must exercise a high degree of professional judgment within scope of licensure.