Chronic Care Navigator

FTMC•Wakeman, OH

36d

About The Position

The Care Navigator in collaboration with the health care team is responsible for overall administration of the Transitional Care Management program and the Chronic Care Management (CCM) program, as well as the specifics services for patients enrolled in each program. The Care Navigator connects with the patient via telehealth, phone, or in person and introduces the TCM program within 1-2 business days after discharge to review discharge instructions, medication reconciliation, social determinants, and assist with appointments as needed.

Responsibilities

Identify appropriate patients for TCM/CCM.
Review with the patient and/or family the program's services and benefits.
Review and answer question relating to the program's consent requirements.
Develop in conjunction with the patient and/or family and health care team an individualized comprehensive care plan.
Perform monthly services as described within TCM/CCM program.
Document services provided in the record appropriate for reimbursement.
Reviews medication list and identifies area to be reconciled.
Schedule routine and follow-up appointments as indicated.
Monitor minutes of services provided to ensure appropriate time is completed for billing.