Senior Chronic Care Management Coordinator & Trainer (part-time/hybrid)

Description

POSITION SUMMARY
Senior Chronic Care Management (CCM) Coordinator & Trainer is a hybrid position involving the provision of exceptional telephonic care coordination to patients with chronic conditions, as well as leading the refinement of our CCM program workflows and training our nursing staff organization-wide. This role will be a clinical expert, a patient advocate, and a key educator responsible for ensuring program excellence and consistency across the entire organization.

REPORTING RELATIONSHIPS

This position reports to the Associate Vice President of Integrated Primary Health Services.  

ESSENTIAL JOB DUTIES AND FUNCTIONS

While living and demonstrating our Core Values, the Senior Chronic Care Management Coordinator & Trainer will perform the following functions.

Core Care Coordinator Responsibilities

• Patient Outreach & Engagement: Proactively conduct monthly patient calls to assess health status, monitor adherence to care plans, provide crucial education, and build supportive, long-term relationships
• Care Plan Management: Collaborate with patients, primary care providers, and the multidisciplinary care team to develop, implement, and update individualized patient care plans
• Care Coordination: Serve as the primary point of contact for patients, expertly coordinating appointments, services, and communication between various providers, specialists, and pharmacies
• Resource Navigation: Connect patients with essential community resources, entitlement programs, and support services to improve their overall well-being
• Accurate Documentation: Maintain meticulous and timely documentation of all patient interactions, interventions, and care plan updates within the Electronic Medical Record (EMR)
• Compliance & Adherence: Ensure all care coordination activities are performed in strict accordance with Centers for Medicare & Medicaid Services (CMS) guidelines

Training & Implementation Responsibilities

• Workflow Review & Optimization: Analyze existing CCM clinical workflows to identify inefficiencies, bottlenecks, and areas for improvement, and design and propose optimized, standardized workflows to enhance productivity and patient care quality
• Training Development: Create and maintain comprehensive training materials, including manuals, guides, and presentation resources, to support the consistent adherence to the standardized CCM workflow
• Organization-Wide Implementation: Lead the rollout of new and updated workflows across the organization, and conduct training sessions, workshops, and one-on-one coaching for all nurses and clinical staff involved in the CCM program
• Ongoing Support & Quality Assurance: Act as the subject matter expert for CCM processes by providing ongoing support to the nursing team, answering workflow-related questions, and monitoring adherence to ensure consistent implementation and quality standards are met

Requirements

REQUIRED QUALIFICATIONS 

• Meet EOS© People Analyzer Tool embraced and adopted by The Wright Center for Community Health and its affiliated entity The Wright Center for Graduate Medical Education 
• Be fully committed to the framework of, and preferably, have experience working in, the EOS® model
• Be mission-driven
• Represent the enterprise in a professional manner while demonstrating organizational pride
• Have achieved a Bachelor of Science in Nursing or equivalent experience
• Have an active PA RN license
• Demonstrate strong, empathetic communication and interpersonal skills with the ability to build trusting professional relationships and rapport with both patients and clinical staff
• Possess a solid working knowledge of chronic conditions, evidence-based management of chronic conditions, and relevant clinical best practices
• Be proficient in using Electronic Medical Record (EMR/EHR) systems for accurate, timely documentation
• Have a clear understanding of CMS guidelines and billing requirements related to Chronic Care Management
• Have proven experience in clinical training, adult education, and leading process improvement initiatives
• Possess strong analytical skills with an ability to assess and optimize clinical workflows
• Have a demonstrated record of excellent leadership, presentation, and public speaking skills