Chronic Care Management (CCM) Coordinator

Robert C. Byrd Clinic • Lewisburg, WV

2d • Onsite

About The Position

WVSOM Health is expanding its care coordination team and seeking a full-time Chronic Care Management (CCM) Coordinator. The Chronic Care Management (CCM) Coordinator role is responsible for managing all aspects of a patient’s healthcare maintenance and treatment and working collaboratively with the patient and other healthcare professionals to ensure seamless, organized, effective, quality care. The primary role of the CCM Coordinator is to be the patient’s advocate in all aspects of their healthcare journey and is instrumental in assisting them with obtaining appropriate resources, as needed. This role is also responsible to assist the clinic in achieving value-based care goals through multiple insurance quality programs, the Accountable Care Organization (ACO) and the Centers for Medicaid and Medicare Services (CMS). Reviewing and closing care gaps and performing both Chronic Care Management (CCM) and Transitional Care Management (TCM) with CMS patients are important tasks to both the interest of the patient and clinic. This role will develop processes that support these care coordination efforts. Ensure all CMS regulations are met in order to bill and receive reimbursements that support these programs for continued growth.

Requirements

• Knowledge of the regulatory guidelines for Chronic Care Management as outlined by CMS.
• Knowledge of Patient-Centered Medical Home model/mission.
• Experience with health insurance practices and requirements.
• Knowledge and understanding of chronic disease and preventative care measures and their impact on patient health and well-being.
• Good judgement and critical thinking skills are critical.
• Ability to establish and maintain a good rapport with patients, families, medical staff, and coworkers.
• Excellent written and verbal communication skills.
• Strong attention to detail.
• Ability to prioritize and be willing to invest in a change process to improve effectiveness.
• Able to prioritize and work with little supervision.
• Proficient computer skills, including Microsoft Office, and ability to utilize electronic health record.
• A minimum of three years’ experience in a clinical setting
• WV licensure as a Registered Nurse.
• Current BLS Certification.

Responsibilities

• Manage a caseload of an assigned panel of chronic care patients.
• Becomes the point of contact for CCM Patients regarding all care needs (i.e., medication refills, scheduling appointments, answering questions, etc.).
• Collaborate with providers in identifying appropriate patients for care management.
• Develop relationships with patients as an integral member of the care team; always shows compassionate and empathetic care to all clinic patients.
• Provide follow-up management with patients to ensure compliance with their individual care plan.
• Schedule appointments accurately in EHR.
• Anticipate the needs of the patient population, seeing that necessary documentation and pre-visit planning is completed, or medical records are requested, if applicable, before patient visits.
• Promote patient self-management and empower patient to achieve maximum level of wellness and independence.
• Determine and coordinate appropriate referrals as needed.
• Work with patient and patient’s care team to coordinate change readiness, needs assessment, and to develop an individualized treatment care plan.
• Collaborate with the patient, provider, and other care team members in assessing the patient’s progress toward individual health care goals.
• Maintain accessible, consistent documentation of patient self-management measures and progress toward goals using the EHR to allow for proper billing.
• Support patient self-management of disease and behavior modification interventions.
• Assess barriers when patient has not met treatment goals, is not following treatment plan of care, or has not kept important appointments.
• Promote collaborative teamwork and work with peers in a team situation.
• Collaborate with payer Case Managers for additional services when appropriate.
• Develop relationships with medical supply and community resources available to patients.
• Provide follow-up in the transition of care from various settings (hospital or skilled nursing facility discharges and ER visits).
• Coordinate efforts with Care Coordination to achieve goals/metrics for patient care with various insurance companies and the ACO.
• Properly bill for services using appropriate CPT codes.
• Monitors time spent with each patient closely to ensure maximum benefit to the patient.
• Participate in committees as applicable.
• Other duties as assigned.
• All employees must comply with WVSOM Health’s excellent customer service standards.

Benefits

• Comprehensive benefits package including health, dental, vision, life insurance, employer paid long-term disability, retirement savings and match plan
• Paid vacation, sick leave, and holidays
• Qualifying employment for the Public Service Loan Forgiveness (PSLF) Program
• On-campus workout facility that features a regulation basketball court, cardiovascular machines, resistance machines, weights, lockers, and shower facilities
• Collegial team-based work environment
• Opportunity for a balanced professional and personal life

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed