Chronic Condition Manager - Lexington, SC

Marathon Health•Lexington, SC

4d•$75,000 - $95,000

About The Position

Marathon Health is a nationwide advanced primary care provider that partners with employer and union plan sponsors. The Chronic Condition Manager facilitates, develops, monitors, measures, and reports on wellness and chronic disease prevention and management programs that complement Marathon Health's Health Center services. The role educates, counsels, and coaches patients on preventing or managing chronic disease in face-to-face, virtual, and telephonic formats, both individually and in groups. It may also include developing educational materials and coordinating services among client vendors. Duties are performed for a specific client at its various locations. The position manages programs for conditions including diabetes, hypertension, hyperlipidemia, COPD, asthma, obesity, and cardiovascular disease. The Chronic Condition Manager evaluates patients' clinical and educational needs, supports behavior change, coordinates with healthcare teams and vendors, conducts outreach, and documents care in the electronic medical record. The role uses evidence-based medicine and available data to support care decisions, program enrollment, and patient engagement.

Requirements

Registered Nurse (RN) credential.
Minimum of 3 years of experience in chronic disease management, such as diabetes care or cardiac and pulmonary rehabilitation.

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 interest in creating and driving best practices.
Willingness to go the extra mile for patients.
Strong customer service skills.
Ability to work autonomously and independently as well as part of a team.
Demonstrated multitasking competence and 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.

Responsibilities

Facilitate chronic condition management and prevention programs, including diabetes management and prevention, hypertension, hyperlipidemia, COPD, asthma, obesity, and cardiovascular disease.
Develop individualized interventions to improve and maximize health outcomes.
Evaluate patients’ psychosocial, physical, financial, and educational needs, prognosis, and past and present treatment and services.
Identify and enroll individuals who qualify for chronic condition management programs.
Establish supportive and confidential relationships with patients.
Assess patients’ clinical and educational knowledge of their conditions and readiness to change behavior; tailor programs to individual needs.
Collaborate with healthcare team members, including nurse practitioners, physician assistants, medical doctors, and health and wellness coaches.
Conduct outreach by phone, email, and regular mail, including proactive outreach to eligible and unengaged members.
Provide lifestyle and behavior-related health coaching face-to-face, virtually, and by telephone, 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 to condition management.
Participate in analysis of available data, report review, and enrollment strategies for condition management programs.
Use evidence-based medicine in clinical decision-making, including medication management, diagnostic and laboratory testing orders, and patient education and support for healthy lifestyle and behavioral changes.
Complete accurate, timely, and thorough electronic medical record documentation.
Support Marathon Health’s mission, vision, and values; complete mandatory trainings and meetings and follow organizational policies and procedures.
Participate in education sessions coordinated by Marathon clients for eligible patient populations.
Coordinate with other vendors, such as carriers and EAPs, 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, resources, and treatment options appropriate to patient populations.
Perform other duties as assigned.