Chronic Care Manager-GROW Grant

Southern Indiana Community Healthcare•Paoli, IN

6d•$20 - $26

About The Position

The Chronic Care Nurse performs care management for Medicare patients with at least two chronic illnesses, such as chronic kidney disease, diabetes, chronic obstructive pulmonary disease, or congestive heart failure. The nurse works in partnership with patients and their families or caregivers, clinic providers, and community resources to support self-management and shared decision-making. The role promotes and administers the CMS-approved Chronic Care Management (CCM) program in accordance with clinic policies and procedures. The nurse maintains the CCM patient registry, validates enrollment, provides at least 20 minutes of monthly telephone or other non-face-to-face counseling or education to each assigned patient, and documents care management in the electronic medical record. The nurse monitors care plans and patient progress, coordinates access to providers and community resources, supports transitions from inpatient to outpatient care, and provides patient and family education. The position also includes tracking program activity, assisting with program development and related administrative work, participating in training and meetings, and representing Southern Indiana Community Healthcare to external agencies and at community events. The role requires professional, confidential, and effective communication with patients, staff, providers, and community partners.

Requirements

Graduate of an accredited School of Nursing.
Current LPN or RN license in the state of Indiana.
Ability to maintain confidentiality and comply with HIPAA, organizational policies, applicable laws, grant and documentation requirements, information security and patient safety policies, employee conduct standards, and applicable CHW standards and certification requirements.
Effective verbal, written, and electronic communication skills, including the ability to give health presentations to groups in different settings.
Cognitive ability to understand medical terminology, records, and instructions.
Competence using an electronic medical record and following up on CCM responsibilities.
Basic organizational skills and ability to work independently and as part of a team.
Ability to use Microsoft Word, Excel, Publisher, and Office 365, and access web-based applications and programs.
Ability to select from alternatives when responding to situations encountered on the job.
Ability to use appropriate body mechanics when transferring or assisting patients with walking and dressing, and to lift up to 40 pounds.

Nice To Haves

One to three years of work experience in a healthcare setting involving patients with complex chronic disease states is preferred.

Responsibilities

Provide appropriate physical, emotional, and spiritual care consistent with the clinic's mission.
Build and maintain professional relationships with providers, staff, and patients; promote the CMS-approved CCM program and follow organizational policies and objectives.
Maintain the chronic care management patient registry and validate patient enrollment based on provider requests.
Conduct at least 20 minutes per month of telephone or other non-face-to-face counseling or education with each CCM patient on the assigned roster.
Carry out care plans with patients, families or caregivers, and providers, and document care in the electronic medical record.
Monitor adherence to care plans and patient progress, evaluate effectiveness, and facilitate changes as needed.
Establish an ongoing process for patients and caregivers to identify and request their desired level of care coordination support.
Facilitate patient access to appropriate medical and specialty providers.
Oversee transitions from inpatient to outpatient care to help decrease readmissions and partner with the transition-to-care management team.
Work with office providers on day-to-day calls involving symptom control and medication management, and provide patient and family education.
Educate patients and caregivers about relevant community resources.
Help identify high-risk patients and enroll them in the patient registry.
Coordinate continuity of care with external healthcare organizations and facilities, including referrals from primary to specialty care.
Support patient self-management of disease and behavior modification.
Provide health counseling, education, and instructions to patients.
Track and report patient numbers; complete assigned paperwork by month-end and use Excel tracking sheets to document daily, weekly, and monthly work.
Assist in developing programs using the chronic care model and assist the Enabling Services Director and CHW as needed.
Participate in webinars, conferences, approved training, in-services, and required meetings to improve job-related knowledge and support program goals.
Plan or assist with public relations activities, including health fairs and other public events.
Represent Southern Indiana Community Healthcare effectively to external agencies.
Perform related work within the limits of license, certification, and training when providing direct patient care.
Maintain ethical conduct, confidentiality, professionalism, and customer service; communicate effectively in person, in writing, electronically, and through required communication methods.
Use the EMR and assigned web-based applications; prepare basic correspondence and reports and use Microsoft Word, Excel, Publisher, and Office 365.