Chronic Care Management

PRIMARY CARE PARTNERS INC•Grand Junction, CO

3d•$23 - $26•Onsite

About The Position

The Chronic Care Manager provides telephone-based chronic care management for patients with chronic diseases. Under the direction of the Practice Transformation Director, the role coordinates care with patients, families, providers, nurses, and other clinical disciplines, and supports patients in managing chronic conditions and making lifestyle changes to mitigate health risks. The position includes patient education and clinical health coaching, medication and appointment management, care-plan monitoring, and connecting patients and families with appropriate medical, specialty, and community resources. The role also supports hospital transitions by reviewing daily discharge reports, completing transition-of-care assessments within two days of discharge, reviewing discharge instructions and reconciling medications, and facilitating follow-up visits within seven days, including the day of discharge. The Chronic Care Manager documents required elements for CCM billing and bills according to CMS guidelines, participates in quality improvement and care coordination activities, and maintains patient confidentiality and standards of care. This is a full-time, 40-hour-per-week position. Work is primarily Monday through Friday, between 8:00 a.m. and 5:00 p.m.; expected hours may change with or without notice. The position is based in Grand Junction, Colorado.

Requirements

Medical Assistant qualification.
At least two years of experience providing nursing care to chronically ill patients, especially in home health or primary care settings.
Experience working in an electronic medical record (EMR) system.
Active listening skills and effective written and verbal communication.
Excellent time management skills.
Knowledge of privacy policies and ability to maintain confidentiality of patient health information.
Adherence to high standards of personal and professional conduct.

Responsibilities

Make outgoing calls and communicate with provider-designated CCM patients to support management of chronic diseases.
Respond to incoming telephone calls from CCM patients.
Educate patients and families about chronic conditions, treatment regimens, medications, and lifestyle changes.
Assist with medication management and appointments with primary care and specialist providers.
Provide clinical health coaching and interventions to encourage successful self-management of chronic disease.
Partner with patients, families, provider practice teams, and clinical staff to coordinate care and mobilize community resources.
Maintain knowledge of community services and partners involved in or available to support patient care.
Develop, contribute to, and modify patient care plans based on mutual goals, medical summaries, and ongoing action plans.
Monitor patient adherence and progress toward care-plan goals, and facilitate changes when needed.
Facilitate access to appropriate medical and specialty providers as indicated by a physician or qualified healthcare provider.
Bill for CCM in accordance with CMS guidelines and document all required CCM billing elements.
Use the family division's daily discharge report to support hospital-discharge follow-up.
Complete transition-of-care patient assessments within two days of discharge.
Review discharge instructions and reconcile medications.
Facilitate follow-up visits for family divisions within seven days, including the day of discharge.
Coordinate access to primary care and care coordination support for unmet social needs, transitions, and referrals to care management.
Participate in office meetings related to performance improvement, quality reports, electronic health record enhancements, and budgeting.
Attend and actively participate in care coordination training and meetings, including health coach activities, workshops, webinars, cohort calls, and one-on-one meetings as needed.
Provide a high standard of nursing care while following company policies, procedures, and standards of care.
Protect the confidentiality of patients' personal health information and maintain professional conduct.