Chronic Condition Manager - RN - Anderson, SC

MH Health Care Services PC•Anderson, SC

7h•Hybrid

About The Position

Marathon Health is a leading advanced primary care provider that partners with employer and union plan sponsors to improve health for millions of Americans. With nationwide onsite, nearsite, and network health centers, and virtual primary care, Marathon delivers a value-based model that enhances the healthcare experience for members and providers, while driving meaningful cost savings for plan sponsors. Marathon is proud to be certified as a Great Place to Work®, reflecting the company's commitment to building an inclusive, high-trust culture where all employees can thrive. The Chronic Condition Manager will facilitate, develop, monitor, measure, and report on wellness and chronic disease prevention and management programs that complement the Health Center maintained and coordinated by Marathon Health. The role involves educating, counseling, and coaching patients on how to prevent and/or manage chronic disease in various formats (face-to-face, virtual, telephonic) and settings (one-on-one, group). The CCM may also be responsible for developing educational materials and coordinating efforts among client vendors for cohesiveness of services and client population engagement.

Requirements

Registered Nurse (RN) or Bachelor’s degree in Nursing (BSN)
Minimum 3 years’ experience in chronic disease management (Diabetes Care, Cardiac and Pulmonary Rehabilitation, etc.)

Nice To Haves

Certified Diabetes Care and Education Specialist (CDCES) strongly preferred
Passionate about transforming the way healthcare is delivered.
Passionate about the patient experience.
Desire to improve the quality of care for people.
Enjoy working in a collaborative team environment where patients come first
Entrepreneurial spirit and a passion for creating and driving best practices.
Willingness to go the extra mile for patients.
Great customer service skills.
Ability to work autonomously.
Demonstrated competence in multi-tasking
Excellent critical thinking skills
Experience leading and developing presentations.
High energy personal style and aptitude for process-oriented thinking
Track record of consistent, stable employment along with the ability to work independently and as a part of a team

Responsibilities

Facilitates chronic condition management and prevention programs, including but not limited to: Diabetes Management, Diabetes Prevention, Hypertension Management, Hyperlipidemia Management, COPD, Asthma, Obesity and Cardiovascular Disease. Programs include clinical, educational, and health coaching components
Develops individualized interventions designed to improve and maximize health outcomes
Conducts thorough and objective evaluations of the patients’ status, including psychosocial, physical, financial, and educational needs, prognosis, and past and present treatment course and services
Identifies and enrolls individuals that qualify for chronic condition management programs
Establishes supportive and confidential relationships with patients
Assesses patients’ clinical and educational knowledge of chronic condition, readiness to change behavior and individualizes program/s based on needs
Collaborates with other members of the healthcare team, such Nurse Practitioners, Physician Assistants, Medical Doctors, Health and Wellness Coaches, to optimize care and solve problems
Conducts outreach via phone, email and regular mail
Provides face-to-face, virtual and telephonic lifestyle and behavior-related health coaching in both individual and group settings
Reviews HRA results, if applicable, and provides education and counseling to patients based on risk factors
Follows workflow and policy guidelines for documentation in the electronic medical record, including the utilization of predictive modeling and behavior change analytics tools
Applies critical thinking skills and problem-solving techniques to the condition management process
Participates in the analysis of available data, review of reports, and strategy for enrollment of members to condition management programs
Performs in-person, virtual, telephonic, and/or electronic proactive outreach to members that are eligible for disease management programs, as well as to unengaged members
Utilize Evidence Based Medicine in clinical decision making particularly with medication management, diagnostic and lab testing orders, and providing support/education to patients in making healthy lifestyle & behavioral changes.
Completes accurate, timely and thorough documentation in EMR system.
Support the mission, vision, and values of Marathon Health.
Participate in and complete all mandatory Marathon Health trainings and meetings and comply with organizational policies and procedures.
Participates in education sessions coordinated by Marathon clients for their respective, eligible patient population
Coordinates efforts with other vendors (carriers, EAP, etc.) to inform client population of all available resources
Communicates with Marathon Corporate and/or carrier to provide compliance-related information and necessary documentation
Directs patients to onsite providers, primary care physicians, and/or specialists, as needed
Maintains current knowledge of disease processes, available resources, and treatment options appropriate to patient populations.
Performs other duties as assigned