Chronic Care Management Specialist

Community action committee of pike county•Piketon, OH

63d

About The Position

The Chronic Care Management (CCM) Specialist plays a vital role in improving health outcomes for individuals with chronic health conditions by providing patient education, support, and guidance. This position engages with patients, their families, and the community to address health needs, ensure access to appropriate resources, and support adherence to care plans. The CCM Specialist serves as a bridge between healthcare providers and the community, ensuring individuals receive the necessary care and support to manage their conditions effectively.

Requirements

Licensed Practical Nurse (LPN) or Community Health Worker (CHW) required.
Valid Ohio Driver's License, clean driving record, and reliable transportation.
Insurable under agency policy.
Proficiency in Microsoft Office applications.
Knowledge of chronic diseases such as diabetes, hypertension, asthma, and heart disease.
Friendly, professional, and courteous demeanor.
Strong communication skills with the ability to interact productively with senior staff, CAC department staff, community partners, and clients.
Active Ohio LPN license or CHW certification.

Responsibilities

Serve as the primary point of contact for patients enrolled in Chronic Care Management programs.
Assist patients in understanding their chronic conditions (e.g., diabetes, hypertension) and the importance of treatment adherence.
Provide emotional support and encouragement to help patients manage their conditions.
Collaborate with healthcare providers to implement individualized care plans.
Review and update care plans routinely.
Provide clinical support and care management, education, self-management support, and ongoing communication with patients on a CCM registry.
Help patients understand their care plans and assist with follow-up appointments, lab tests, and medication management.
Ensure that patients receive timely referrals to specialists, social services, or community resources as needed.
Provide education to patients and their families on disease prevention, self-management techniques, nutrition, physical activity, and medication adherence.
Support patients in setting and achieving health-related goals.
Engage with local organizations, community groups, and healthcare systems to raise awareness of CCM programs and resources.
Work collaboratively with interdisciplinary care teams, including nurses, physicians, social workers, and other healthcare professionals.
Empower patients to take an active role in managing their health by promoting self-advocacy.
Help patients navigate healthcare systems and insurance benefits to reduce barriers to care.
Maintain accurate and up-to-date patient records in the Electronic Health Record (EHR) system, documenting interactions, care coordination, and progress toward health goals.
Collect and report on patient outcomes, satisfaction, and engagement metrics to help improve the program's effectiveness.
Demonstrate an understanding of systems of care, entitlements and benefits, and cultural awareness.
Maintain a courteous and professional demeanor with customers, staff, funders, and community partners while promoting a positive reflection of CAC and the Community Empowerment Department.
Demonstrate the ability to work cooperatively with individuals to determine needs and build on their ability to succeed in the community.
Maintain required records and handle confidential information in a professional manner, including HIPAA compliance.
Attend meetings, conferences, and trainings related to the duties of this position, and disseminate information to appropriate individuals.
Participate in CAC committee assignments and other agency service duties as assigned.
Perform other tasks and duties as assigned by supervisor.