Chronic Condition Manager - Lexington, SC

Marathon Health•Lexington, SC

About The Position

Marathon Health is seeking a Chronic Condition Manager to facilitate, develop, monitor, measure, and report on wellness and chronic disease prevention and management programs that complement its Health Center services. The role educates, counsels, and coaches patients on preventing or managing chronic disease through face-to-face, virtual, and telephonic interactions, both individually and in groups. The manager may develop educational materials and coordinate services among client vendors to improve cohesion and engagement. Duties are performed for a specific client across its various locations. The Chronic Condition Manager supports programs for conditions including diabetes, hypertension, hyperlipidemia, COPD, asthma, obesity, and cardiovascular disease. The work combines clinical, educational, and health coaching components, with individualized interventions intended to improve health outcomes. The role assesses patients’ clinical, psychosocial, physical, financial, and educational needs; supports behavior change; coordinates with healthcare teams and vendors; and documents care in the electronic medical record. The manager uses evidence-based medicine and available analytics and data to guide care and program enrollment, while maintaining current knowledge of disease processes, resources, and treatment options.

Requirements

Registered Nurse (RN) credential required.
At least 3 years of experience in chronic disease management, such as diabetes care or cardiac and pulmonary rehabilitation.
Ability to work autonomously and independently as well as collaboratively with a team.
Demonstrated competence in multitasking.
Excellent critical thinking skills.
Track record of consistent, stable employment.

Nice To Haves

Certified Diabetes Care and Education Specialist (CDCES) certification is strongly preferred.
Passion for transforming healthcare delivery and improving the patient experience and quality of care.
Enjoy working in a collaborative, patient-first team environment.
Entrepreneurial spirit and passion for creating and driving best practices.
Willingness to go the extra mile for patients.
Strong customer service skills.
Experience leading and developing presentations.
High-energy personal style and aptitude for process-oriented thinking.

Responsibilities

Facilitate chronic condition prevention and management programs, including diabetes, hypertension, hyperlipidemia, COPD, asthma, obesity, and cardiovascular disease programs.
Develop individualized interventions designed to improve and maximize health outcomes.
Evaluate patients’ psychosocial, physical, financial, and educational needs, prognosis, and past and present treatment course and services.
Identify and enroll eligible individuals in chronic condition management programs.
Establish supportive and confidential relationships with patients and assess their clinical and educational knowledge, readiness to change, and individual program needs.
Collaborate with healthcare team members, including Nurse Practitioners, Physician Assistants, Medical Doctors, and Health and Wellness Coaches, to optimize care and solve problems.
Conduct patient outreach by phone, email, regular mail, and in-person, virtual, telephonic, or electronic channels.
Provide lifestyle and behavior-related health coaching in individual and group settings.
Review health risk assessment results, when applicable, and provide education and counseling based on risk factors.
Follow workflow and policy guidelines for electronic medical record documentation, including use of predictive modeling and behavior change analytics tools.
Apply critical thinking and problem-solving techniques to condition management.
Participate in analysis of available data, report reviews, and strategies for enrolling members in condition management programs.
Use evidence-based medicine in clinical decision-making, including medication management, diagnostic and lab testing orders, and support and education for healthy lifestyle and behavioral changes.
Complete accurate, timely, and thorough documentation in the electronic medical record.
Support Marathon Health’s mission, vision, and values; complete mandatory trainings and meetings; and comply with organizational policies and procedures.
Participate in education sessions coordinated by Marathon clients for their eligible patient populations.
Coordinate with other vendors, such as carriers and EAP, to inform client populations about available resources.
Communicate compliance-related information and necessary documentation to Marathon Corporate and/or carriers.
Direct patients to onsite providers, primary care physicians, and/or specialists as needed.
Maintain current knowledge of disease processes, available resources, and treatment options appropriate to patient populations.
Perform other duties as assigned.