Bullhook Community Health Center (BCHC) is an equal opportunity employer. BCHC shall, upon request, provide reasonable accommodation to otherwise qualified individuals with disabilities.
Job Title: Chronic Care Management Supervisor
Department: CMO Department
Salary: $43,212.00 - $61,609.98
Employment Type: Full-time
Job Overview
Individual will be responsible for assisting medical providers in the management of high risk chronic illness patients to promote effective education, self‑management support, and timely healthcare delivery to achieve optimal quality and financial outcomes.
Responsibilities
Collaborates with providers and clinic staff in identifying appropriate patients for care management, utilizing established care management criteria.
Performs initial and periodic holistic assessments for care‑managed population including physical and psychological assessments and Medicare Annual Wellness Visits as appropriate.
Prioritizes patients according to medical complexity, need, and required follow up.
Forms and implements a care management plan addressing patients' identified needs, assessing patient and family needs, issues, resources, and care goals; determining choices available to patients; educates patients/families on choices.
Establishes a person‑centered electronic care plan mutually agreed upon by the health care team and the patient/family, containing specific self‑management goals, objectives, and action‑oriented interventions.
Evaluates effectiveness of the plan in meeting established care goals and revises as needed.
Monitors and evaluates patient progress.
Collaborates with the healthcare team to revise the care management plan when changes occur.
Initiates care conferences to discuss multidisciplinary team responsibilities, patient progress, new problems, etc.
Identifies and effectively utilizes community resources to meet needs of patients/families; facilitates patient access to community resources as appropriate.
Promotes patient self‑management and empowers patients/families to achieve maximum wellness and independence.
Interacts professionally with patient/family, involving them in plan of care formation.
Performs follow‑up calls for patients recently discharged from acute hospitalizations.
Maintains EMR database on care‑managed population and ensures accurate, timely documentation.
Reviews utilization and quality reports monthly, scanning for gaps in care to identify patients needing additional support.
Ensures all CMM rules and requirements are met.
Performs medication reconciliation for all care transitions.
Participates in community preventative health activities (e.g., school‑based flu clinics).
Participates in orientation of new personnel.
Meets monthly, quarterly, and yearly metrics as indicated.
Precepts and mentors peers.
Promotes collaborative teamwork.
Abides by the organization’s compliance program and requirements.
Provides coverage across the organization as needed.
Works collaboratively with leadership to improve care delivery through evaluation, development, and enhancement of policy and procedures.
Performs other duties as assigned.
Minimum Qualifications
Minimum of 3 years of professional level medical experience; care coordination experience strongly preferred.
RN or LPN licensure preferred; certified Medical Assistant with extensive care coordination experience considered.
Experience working with an electronic medical record required.
Ability to work collaboratively with people of diverse cultures and lifestyles.
Excellent organizational skills and ability to handle multiple priorities while remaining calm.
Strong oral and written communication skills.
Self‑motivated and able to work independently.
Proficient computer skills from expert level.
Problem solving skills.
Proficiency in medication indications and side effects.
Understanding of medical tests and requirements to provide appropriate information to patients.
Knowledge, Skills and Abilities (KSA’s)
In-depth knowledge of clinical nursing principles, practices, and procedures.
Knowledge of community health center laws and regulations.
Thorough knowledge of phlebotomy, immunizations, communicable diseases, CPR, and other nursing procedures.
Knowledge of mental health and substance use disorders, treatments, and crisis intervention management.
Excellent communication with clients, families, employees, and health care professionals.
Strong organizational skills to manage multiple priorities effectively and professionally.
Ability to work independently and be self‑directed and flexible.
Ability to prioritize and perform functions with minimal supervision.
Ability to work at a high‑volume level of accuracy.
Physical and Environmental Demands
Work performed in an office and clinic setting; stands, walks with intermittent sitting; reaches for and uses writing instruments and keyboard; reads reports and written materials; extensive use of telephone and oral communication with the public and coworkers; stoops, bends, kneels, reaches, picks up, and pushes or pulls; ability to lift up to 30 pounds.
Special Requirements
The specific statements shown in each section of this description are not intended to be all inclusive. They represent typical elements and criteria considered necessary to perform the job successfully.