Chronic Care Management

Chronic Care Management Supervisor

Bullhook Community Health Center (BCHC) is an equal opportunity employer. BCHC shall, upon request, provide reasonable accommodation to otherwise qualified individuals with disabilities.

Job Overview: The 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 include coordinating patient care to improve quality of care through the efficient use of resources and thereby enhancing quality, cost-effective outcomes. Acts as an advocate for the individual's healthcare needs, and coordinates care to minimize the fragmentation of health care delivery systems. This position is committed to the constant pursuit of excellence in improving the health status of the community.

Essential Functions (Major Duties or 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.
• Prioritizes patients according to medical complexity, need and required follow up.
• Formulates and implements a care management plan that addresses the patients identified needs.
• Establishes a person-centered electronic care plan that is mutually agreed upon by the health care team and the patient/family.
• Evaluates the effectiveness of the plan in meeting established care goals.
• Monitors and evaluates the progress of the patient.
• 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 the needs of patients/families.
• Promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence.
• Maintains EMR database on care managed population.
• Reviews utilization and quality reports monthly and scans for gaps in care to identify patients needing the additional support of care management.
• Ensures all rules and requirements set forth by the Centers for Medicare and Medicaid for Chronic Care Management are being met.
• Performs medication reconciliation for all care transitions.
• Participate in community preventative health activities.
• Participates in the orientation of new personnel.
• Meets monthly, quarterly, and yearly metrics as indicated.
• Precepts and mentor's peers.
• Promotes collaborative teamwork.
• Abides by the organization's compliance program and requirements.
• Provides coverage across the organization as needed.
• Works collaboratively with leadership team to improve and enhance care delivery.
• Performs other duties as assigned.

Minimum Qualifications (Education and Experience): Minimum of 3 years of professional level medical experience; experience in care coordination strongly preferred. RN or LPN licensure preferred. A certified Medical Assistant with extensive care coordination experience will be considered.

Knowledge, Skills and Abilities (KSA's): Knowledge of principles, practices, and procedures of clinical nursing. Related community health center laws and regulations. Thorough knowledge of phlebotomy, immunizations, communicable diseases, CPR, and other related nursing procedures. Thorough knowledge of mental health and substance use disorders, treatments and crisis intervention management. Ability to perform nursing duties in a professional manner. Communicate with clients, families, employees, and health care professionals. Good organizational skills to handle multiple priorities while remaining professional and calm. Ability to work with many diverse people. Effective telephone skills. Strong level of confidentiality due to the sensitivity of materials and information handled. Ability to make suggestions on workflow or system efficiency and effectiveness. Ability to work independently and be self-directed and flexible. Ability to prioritize. Ability to perform functions with minimal supervision. Ability to work at a high-volume level of accuracy.

Supervision: N/A

Physical and Environmental Demands: Work is performed in an office and clinic setting; stands, walks with intermittent sitting; reaches for and uses writing instruments and keyboard; reads reports and other written materials; extensive use of telephone and oral communication with the public and coworkers; stoops; bends; kneels; reaches for; 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.