Chronic Care Coordinator (CCM)

POSITION DESCRIPTION

Title: CCM Care Coordinator (Remote)

Direct Report: CCM Supervisor

Indirect Supervisor: VP of Clinical Operations

Classification: Non-Exempt

Department: Clinical Team, CCM

Summary: This position is responsible for the management of the assigned patient population. The Chronic Care Management (CCM) Care Coordinator provides telephonic Chronic Care Management for patients under the direction of the patient’s physician. This position is responsible for maintaining a caseload of chronically ill patients and providing outreach at least monthly to monitor, offer guidance, and provide education related to their conditions and needs.

Essential Functions:

• Provide monthly telephonic outreach, or more frequently as needed, to enrolled patients to offer support and assess patient needs
• Review medical records from various sources to assess gaps in care, evolving needs of the patient, potential inpatient stays, referrals to community and health care agencies, etc.
• Collaborate with the patient to create care plans that are individualized, reviewed routinely and updated appropriately
• Respond in accordance to program guidelines to incoming telephone calls from patients requiring medical guidance
• Act as case manager for patients on behalf of the PCP to initiate appropriate referrals related to patient care as well as community-based support services
• Maintains effective communication with physician, office staff, ACO preferred partners, Lead CCM Care Coordinator, and TCM team, when appropriate
• Attends monthly meetings with assigned practices to review patients and maintain strong relationships between PCPs, office staff, and the ACO
• Maintains and manages caseload effectively and demonstrates ability to organize work flow while adjusting for rapidly changing priorities to meet patient needs
• Documents patient care concisely and professionally according to Commonwealth policy and professional standards
• Exemplifies the mission and values of the organization
• Other duties as assigned or apparent
• This is a remote position, however occasional in-person meetings are required

Competencies:

Adaptability—Accepts criticism and feedback. Adapts to changes in the work environment. Changes approach or method to best fit the situation. Manages competing demands

Communications—Exhibits good listening and comprehension. Expresses ideas and thoughts in written form

Cooperation—Displays positive outlook and pleasant manner. Establishes and maintains effective relationships. Exhibits tact and consideration. Offers assistance and support to co-workers. Works actively to resolve conflicts.

Customer Service—Displays courtesy and sensitivity. Manages difficult or emotional customer situations. Meets commitments. Responds promptly to customer needs.

Dependability—Follows instructions and responds to management direction. Keeps commitments. Meets attendance and punctuality guidelines. Responds to requests for service and assistance. Takes responsibility for own actions.

Quality—Applies feedback to improve performance. Demonstrates accuracy and thoroughness. Displays commitment to excellence. Looks for ways to improve and promote quality.

Qualifications:

Education— Licensed Practical Nurse or Registered Nurse

Experience—Minimum 2 years with preferred 3 years of nursing experience. Case management, home care, and/or telephonic experience preferred.

Computer Skills—Proficient in Microsoft Word and Excel. Understands essential functions and is able to navigate Electronic Medical Records.

Language Ability—Read, analyze and interpret business and medical documents. Write reports, business correspondence and medical documentation. Effectively present information and respond to questions from patients, providers, and partners.

Problem Solving Ability—Solve practical problems and deal with a variety of situations. Ability to determine when to seek input from a supervisor or provider.

Work Environment:

The work environment may be fast paced, and rapidly changing. Changes may occur frequently as we are a growing company. This is predominantly a remote position. A quiet and private work space within the home is required.

Physical Demands:

The position will require long periods of sitting including some bending, stooping, grabbing, typing, squatting, and reaching. The employee may occasionally need to lift up to 25 pounds. Employee will need to routinely use close vision, distance vision, and shift focus rapidly. This position also requires extensive use of hand-eye coordination and manual dexterity for typing.

Acknowledgement:

All elements within the Job Description are not meant to be inclusive of the duties or standards of the position. The employee is still expected to follow duties and instructions as assigned by the supervisor. If the employee needs a reasonable accommodation for any of the elements listed within this job description, s/he should discuss with the supervisor.