Chronic Care Management Specialist

Family HealthCare Network•Farmersville, CA

1d•$21 - $29•Hybrid

About The Position

The Chronic Care Management Specialist provides telephonic, in-person, and electronic support to improve health outcomes for high risk and multiple chronic condition Medicare patients.

Requirements

Possesses work-related skills at a higher level than completion of high school, including formal written and verbal communications skills, computational and computer skills, mathematical, and technical skills.
A combination of relevant experience and completion of high school with a minimum overall GPA of 2.5 or completion of General Educational Development (GED) with a minimum overall score of 162.5, and health care-related knowledge frequently acquired through completion of a trade school, para-professional, or certificate-type program.
If an individual has completed a degree at a higher level than required by the role and had a stronger GPA in that program, they may provide proof of GPA from that degree in lieu of the high school diploma or Bachelor’s degree.
A minimum of three years of experience, knowledge, and training in the field of health care.
Ability to prepare more complex documents in Microsoft Word, including creating tables, charts, graphs, and other elements.
Ability to use Microsoft Excel to review and compile data, including the use of formulas, functions, lookup tables, and other standard spreadsheet elements.
Ability to create basic presentations in Microsoft PowerPoint.
Job duties require the compilation of information prepared in effective written form, including correspondence, reports, articles or other documentation.
Effectively conveys technical information to non-technical audiences.

Nice To Haves

Bachelor's Degree in a related field preferred.

Responsibilities

Supports comprehensive care management of Medicare patients in support of FHCN health-care team by providing twenty minutes of patient education and care coordination monthly to Medicare patients who have two or more chronic diseases.
Outreach to eligible FHCN patients to educate and enroll them in the Medicare Chronic Care Management (CCM) program.
Coordinates the creation of a person-centered, electronic care plan (Comprehensive Care Plan) based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues, with particular focus on the chronic conditions being managed).
Maintains Comprehensive Care Plans by reviewing and updating (if necessary) annually.
Ensure continuity of care with a designated member of the care team with whom the patient is able to schedule successive routine appointments.
System-based approaches to ensure timely receipt of all recommended preventive care services.
Medication reconciliation with review of adherence and potential interactions.
Oversight of patient self-management of medications.
Provide health promotion services similar to the role of a health educator, such as providing training materials and teaching self-management skills pertaining to the patient’s goals identified in the Comprehensive Care Plan.
Encouraging and supporting health education for the patient and family/support persons.
Assessing the patient’s and family/support persons’ understanding of the patient’s health condition and motivation to engage in self‐management.
Coaching patient’s and family/support persons about chronic conditions and ways to manage health conditions based on the member’s preferences.
Linking the patient to resources for smoking cessation, management of chronic conditions, self‐help recovery resources, and other services based on patient needs and preferences.
Using evidence‐based practices, such as motivational interviewing, to engage and help the patient participate in and manage their care.
Utilizing trauma‐informed care practices.
CCM Specialist interfaces with patients and other stakeholders through a variety of mechanisms, including, but not limited to: Individual, face-to-face contacts through both appointment and warm hand-off contacts; Telephone and other electronically mediated contacts; and Contact outside of FHCN Health Centers to provide linkages to appropriate community resources based upon the patients’ identified needs and goals through the Health Action Plan. This could be a mobile unit, for example.
During contacts with health-care team members at FHCN and from other organizations, CCM Specialists reduce barriers to care in a number of ways, including but not limited to: Preparing, printing, and distributing the information necessary for care teams to engage in Pre-visit Huddles.
Maintaining regular communication with care team providers on patient care plan goals and progress.
Facilitating regular communication between the patient and other health-care team members, both inside and outside FHCN.
Providing staff training and education sessions necessary to implement health education and care coordination services.
Participates in meetings and trainings as necessary to facilitate the above duties, including those geared toward implementing evaluation tools that determine the effectiveness of CCM Specialist functions.
Responsible for adhering to the Attendance and Absenteeism Policy, recognizing that regular attendance is considered an essential function of all FHCN positions. Absenteeism is not being at work or failing to attend a paid workshop, training, or event unless the absence is protected by law.
Ability to present to and work at any FHCN location, both at the beginning of a shift or during a shift, based on business need.
Performs other duties as assigned.