Chronic Care Management Coordinator (LPN) Teche Health, A Federally Qualified Health Center, per Section 330 of the Public Health Service Act, is currently seeking qualified applicants for the Chronic Care Management Coordinator position in Franklin, Louisiana.
This is a full-time position. Office hours are Monday - Thursday 7:30am - 5:30pm and Friday 8:00am - 12:00noon.
Job Summary The Chronic Care Management Coordinator (CCM Coordinator) provides care management for adult and pediatric patients with complex illness in the primary care setting, under the supervision of the Chronic Disease Project Manager. In partnership with the primary care practice leadership team, the CCM Coordinator leads care management through process improvement, workflow redesign, training, and delegating to other team members. The CCM Coordinator collaborates with specialists, members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care. The CCM Coordinator assesses plans, implements, coordinates, monitors, and evaluates all options and services to optimize the patient\'s health status. They integrate evidence-based clinical guidelines, preventive guidelines, and protocols to develop individualized, patient-centric care plans that promote quality and efficiency in health care. Other duties may be assigned by the Chronic Disease Project Manager.
Provides targeted interventions to avoid hospitalization and emergency room visits. Coordinates care across settings and helps patients/families understand health care options.
Job Duties And Responsibilities Identifies the targeted CCM population within practice site(s) per PCP referral, risk stratification, and patient lists. Includes patients with repeated social and/or health crises.
Assesses over time the health care, educational, and psychosocial needs of the patient/family. Uses standardized assessment tools such as depression screening, functionality, and health risk assessment.
Collaborates with PCP, patient, and health care team members across continuum of care settings to develop a comprehensive individualized plan of care and targeted interventions. Continuously monitors patient/family response to the plan and revises the care plan as indicated.
Provides patient self-management support with a focus on empowering the patient/family to build capacity for self-care.
Implements systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations.
Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
Coordinates patient care through ongoing collaboration with PCP, patient/family, community, and other health care team members. Fosters a team approach and includes patient/family as active members of the team. Ensures continuity of care beyond the practice; serves as liaison to acute care hospitals, specialists, and post-acute care services.
Provides follow-up with patient/family when transitioning between settings. Completes timely post-hospital follow-up, including medication reconciliation, PCP or specialist follow-up, symptom assessment, teaching warning signs, review of discharge instructions, coordination of care, and problem solving barriers.
Demonstrates excellent written, verbal, and listening communication skills, positive relationship-building, and critical analysis skills.
Maintains required documentation for all care management activities.
Collaborates with practice and leadership to evaluate processes, identify problems, and propose/develop process improvement strategies to enhance care management and the Patient Centered Medical Home delivery model.
Reviews current literature on engagement, care management, and behavior change strategies and incorporates findings into clinical practice.
Participates in/Reports to Quality Assurance Performance Improvement (QAPI) Committee.
Oversees patient evaluation data and makes recommendations to team members accordingly.
Performs other duties as assigned by the Chronic Disease Project Manager.
Skills And Abilities Demonstrates customer-focused interpersonal skills to interact effectively with practitioners, the interdisciplinary health care team, community agencies, patients, and families from diverse backgrounds.
Ability to work autonomously and be accountable for practice.
Ability to influence and negotiate individual and group decision-making.
Ability to function effectively in a fluid, dynamic, and rapidly changing environment.
Demonstrates leadership qualities including time management, verbal and written communication, listening, problem solving, critical thinking, analysis, decision-making, priority setting, delegation, and organization.
Ability to develop positive, longitudinal relationships and set appropriate boundaries with patients/families.
Qualifications To perform this job successfully, an individual must be able to perform each duty described above satisfactorily.
Licensed Practical Nurse, or Master of Social Work license preferred.
Two years of experience with adult medicine and pediatric patients in primary/ambulatory care, home health, skilled nursing facility, or hospital medical-surgical setting within the past five years.
Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education.
Critical thinking and ability to analyze complex data sets.
Ability to manage complex clinical issues using assessment skills and protocols.
Excellent assessment and triage skills; ability to implement evidence-based interventions for chronic conditions.
Excellent verbal and written communication; interpersonal and facilitation skills.
Ability to affect change, work effectively in a team, and adapt to changing needs/priorities.
Time management, priority setting, delegation, and organization.
General computer knowledge and ability to use computer systems.
Associate\'s degree or higher in a clinical field (preferred).
Care management experience (preferred).
Experience in continuous quality improvement (preferred).
Completion of self-management support training (preferred).
Benefits Package Medical, Vision and Dental Health Insurance
Accidental Insurance
Critical Illness Insurance
Long Term Benefits
Short Term Benefits
Free Life Insurance
401K Plan Benefits
Paid Vacation
Paid Sick Time
Set Schedule
No Weekends
National Health Service Corps Site
11 paid holidays
Family-Friendly Work Environment
Eligible for Student Loan Forgiveness through Federal and State Programs
Eligibility Requirements All employees must meet eligibility standards in order to be considered for the position. Internal applicants must be with the organization for at least one year, with no disciplinary actions on file. If you have not been with the organization for a year, approval from your direct supervisor is needed.
Due to CMS Mandate all applicants must be fully vaccinated prior to onboarding with Teche Health with the exception of an approved Medical or Religious Exemption.