Registered Nurse CCM Coordinator - Clayton

Avance Care•Clayton, NC

19d•Onsite

About The Position

Join our expanding Chronic Care Management (CCM) team within Avance Care, a leading network of 36 practice locations across the Triangle Area (Raleigh-Durham-Chapel Hill), the Charlotte Region, and Wilmington, NC. At Avance Care, we are dedicated to elevating the standard of healthcare. As one of North Carolina's largest networks of independent primary care practices, we provide comprehensive, patient-centered services that support the physical, mental, and emotional well-being of our patients. We are recruiting for a Registered Nurse (RN) to support CCM at our Clayton location. This role will provide comprehensive, patient-centered care for a designated population while optimizing health outcomes. The CCM RN Coordinator is responsible for establishing, implementing, monitoring, and evaluating high-quality, cost-effective care plans as patients transition across the care continuum. • This is a Monday – Friday, 8:00 AM – 5:00 PM role, based at our Clayton location.• Supportive Work Environment: We provide a collaborative and encouraging atmosphere where your contributions directly enhance patient health and well-being. You'll also have opportunities for professional growth while making a meaningful impact in the lives of those we serve.• Comprehensive Benefits: Our robust benefits package becomes available starting on the first of the month following 30 days of employment. All offers of employment are contingent upon the successful completion of a background check and drug screen. Avance Care provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to religion, race, creed, color, sex, sexual orientation, gender identification, alienage or citizenship status, national origin, age, marital status, pregnancy, disability, veteran or military status, predisposing genetic characteristics or any other characteristic protected by applicable federal, state or local law.

Requirements

Candidates should have a related degree (ADN or BSN)
Active Registered Nursing license
At least 3 years of direct patient care experience
Strong verbal and written communication
Ability to maintain confidentiality and integrity
Growth mindset
Flexibility and resilience
Knowledge of common medical terminology and HIPAA regulations.
Ability to work collaboratively in a team-oriented environment.

Nice To Haves

Experience in Case Management
Home health nursing
Health coaching/education
Medication administration
Geriatric care

Responsibilities

Review patients’ medical and social health status using electronic medical records, claims data, and community resources.
Conduct outreach to confirm diagnoses, contributing factors, anticipated treatment plans, and barriers to care.
Facilitate access to necessary care by navigating barriers, advocating for patients, and educating families/caregivers.
Monitor patients enrolled in care management to ensure treatment goals are met and communicated across care teams.
Track and support patients post-hospitalization or ER visits to ensure continuity of care and reduce readmission risks.
Assist in primary care provider triage assessments and direct patients to appropriate services.
Provide clinical supervision for LPNs, MAs, and CNAs in case conferencing and approve care plans.
Assist with Medicare physicals.
Maintain accurate documentation in the electronic medical record and communicate updates to care teams.
Identify workflow improvements to enhance cost-effective, high-quality care delivery.
Stay updated on healthcare regulations, trends in ambulatory and cross-continuum care, and accountable care organizations.
Utilize information technology to identify high-risk patients and address care gaps.
Develop and maintain relationships with internal and external stakeholders.