Chronic Care Manager
Description
You will connect with your patients in the practice, by phone, electronically, or in the home as needed. The primary focus of the role will be to work closely with your patients to support them in becoming active in their health care, better understanding their illness and coordinating their care.
Responsibilities
• Conduct comprehensive assessments that include the medical, behavioral, pharmaceutical and social needs of the patient, identify gaps in care and barriers to attaining improved health;
• Based on this assessment, and in conjunction with the patient, the patient’s provider, and other members of the care team, create and implement a care plan that will address the identified needs, remove the barriers and improve the health of the patient;
• Coordinate care by serving as the advocate and resource for the patient, their family and their physician, building effective relationships in the community and across the continuum of care;
• Assess the patient’s knowledge of their clinical condition and provide education and self-management support based on the patient’s unique learning style;
• Provide clinical oversight to non-licensed support staff (e.g. health coaches, patient navigators, community health specialists, etc.) and delegate supportive tasks as appropriate
• Work with the patient and their caregiver to increase their self-efficacy and ability to play a central role in their care;
• Measure, improve and maintain quality outcomes (clinical, financial, and functional) for individual patients and the population served
• Other duties as needed
Qualifications
Required
• 3-5 years of nursing experience, preferably in home health, ambulatory care, community public health, case management, or care coordination across multiple settings and with multiple providers
• Current Licensed Nurse, LPN or RN
Preferred
• Familiarity with the community we are serving or commitment to learn and understand through on the ground networking, community assessment, etc.
• Knowledge and experience activating patients and teaching self-management skills
• Experience working with vulnerable populations (geriatrics, minorities, behavioral health)
• Ability to navigate ambiguity with the aid of structured problem solving techniques
• Exceptional communication skills, both written and oral, ability to positively influence others with respect and compassion
• Strong work ethic built on a foundation of proactivity, collaboration, and teamwork
• Committed to the practice of inquiry and listening
• Embraces electronic health records
• Demonstrates curiosity of learning and receiving critical feedback to further growth and development
Receipt for Position Description
I acknowledge I have read this job description and fully understand the requirements and expectations set forth therein. Furthermore, I have received a copy of the most recent version of my Position Description; I am able to complete all job responsibilities with or without reasonable accommodation.
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