LPNII
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About The Position
The Chronic Care Management position involves working closely with patients primarily through telephone communication to help them achieve their health goals as set by their healthcare providers. This role requires reviewing care plans with patients, conducting chart reviews, and ensuring reconciliation of care plans. The position is focused on assisting patients in managing chronic diseases through effective telephone interactions, providing guidance and support as needed. Additionally, the role includes facilitating access to community resources and assistance, which is crucial for patient support. In this position, you will be responsible for facilitating routine appointment bookings and providing reminders to patients. You will coach patients and their families towards successful self-management of chronic diseases, utilizing tools and documents that support a guided care process. Collaboration with patients and their families is essential to develop an effective plan of care that promotes health behaviors across diverse populations. You will also assess patients' medical, functional, and psychosocial needs, perform medication reconciliation, and review adherence to medication self-management. The Transitional Care Management aspect of the role involves contacting patients after hospital discharge to review discharge instructions, ensuring that patients understand their medications, and coordinating follow-up appointments. You will assist patients in managing transitions between healthcare providers and settings, including making referrals and scheduling follow-up appointments after visits to emergency departments or discharges from hospitals and skilled nursing facilities. Effective communication of relevant patient information through electronic exchange of summary care records with other healthcare providers is also a critical component of this role.
