This position is responsible for providing care coordination services for identified patients eligible for Medicare's Chronic Care Management (CCM) services. Working closely with our Care Manager, the CCM nurse will provide outreach calls to patients enrolled in our Chronic Care Management Program.
- Use Telemedicine/Unified Communications and dynamic care plan to reach out to patients for their scheduled monthly health coaching call and/or Remote Patient Monitoring alerts using an established protocol.
- Apply the principles of comprehensive, community-based, patient-centered care principles.
- Developmentally appropriate, culturally and linguistically sensitive care coordination services.
- Demonstrate excellent customer service skills by following specific scripting requirements during all telephone interactions to ensure call quality and standardization.
- Complete health risk assessments as a foundation for developing individualized care plans and outcomes goals for patients, families and caregivers.
- Provide non-face to face assessments of patients with 2 or more chronic conditions and communicate any concerns to the provider and care team as appropriate.
- Document all patient calls in the care plan and/or EHR and help patients meet goals outlined in the provider's care plan.
- Conduct and document assessments of patient needs and resources for effective self-care management.
- Develop and maintain relationships among patients, families and caregivers, and the patient's care team that support patients' access to the medical home.
- Provide education to patients with chronic conditions on the importance of medication compliance, diet, exercise etc., and ensures patients are following provider instructions for upcoming visits.
- Act as the primary contact point, advocate and source of information for patients, and the community partners who help treat them.
- When assessment an RPM alert, follow established protocols to educate the patient and triage patients as needed.
Skills and Abilities:
- Excellent interpersonal, written, and verbal communication skills.
- Demonstrate flexibility, enthusiasm and willingness to cooperate while working with others in multi-disciplinary teams with activities to include participating in daily huddles.