Registered Nurse - Chronic Care Management

Owensboro Health

About The Position

Coordinates care for patients with multiple chronic conditions, promoting health outcomes through proactive engagement, disease management, and collaboration with providers and care teams.

Requirements

Requires critical thinking skills and decisive judgment.
Works under general supervision.
Must be able to work in a stressful environment and take appropriate action.
Applies more advanced skills and knowledge in the area of specialization.
A minimum of 4 years’ relevant experience required
Associate's degree or higher or Diploma in Nursing required upon hire AND Bachelor's degree or higher in Nursing required within 5 years of employment in this position
RN - Licensed as a Registered Nurse. Eligible to practice nursing in the State of Kentucky required upon hire AND BLS - Certified as a Basic Life Support Healthcare Provider required within 45 days of employment in this position

Responsibilities

Conducts monthly outreach and counseling for patients enrolled in the Chronic Care Management (CCM) program.
Develops, implements, and updates individualized care plans in collaboration with providers and patients.
Monitors symptoms, medication adherence, and chronic disease progression, intervening early to prevent complications.
Coordinates care across primary care, specialists, community resources, and ancillary services.
Provides patient education and coaching to support self-management and behavior modification.
Documents all care coordination activities, including time tracking and care plan updates, in compliance with Centers for Medicare & Medicaid Services (CMS) requirements.
Communicates patient concerns, changes in condition, or barriers to care to the appropriate provider and participates in interdisciplinary team meetings.
Validates CCM patient enrollment and maintains accurate registry and documentation in the electronic health record.
Facilitates patient access to appropriate medical and specialty providers and relevant community resources.
Supports quality improvement initiatives related to chronic disease management and population health.