Registered Nurse - Chronic Care Management

Entity: Owensboro Health Medical Group | Department: Premier Primary Care | Work Hours: M-F | Weekend Requirements: As Needed | 1.0 FTE

Job Summary:

Coordinates care for patients with multiple chronic conditions, promoting health outcomes through proactive engagement, disease management, and collaboration with providers and care teams.

Job Responsibilities:

• Conducts monthly outreach and counseling for patients enrolled in the Chronic Care Management (CCM) program.

• Develops, implements, and updates individualized care plans in collaboration with providers and patients.

• Monitors symptoms, medication adherence, and chronic disease progression, intervening early to prevent complications.

• Coordinates care across primary care, specialists, community resources, and ancillary services.

• Provides patient education and coaching to support self-management and behavior modification.

• Documents all care coordination activities, including time tracking and care plan updates, in compliance with Centers for Medicare & Medicaid Services (CMS) requirements.

• Communicates patient concerns, changes in condition, or barriers to care to the appropriate provider and participates in interdisciplinary team meetings.

• Validates CCM patient enrollment and maintains accurate registry and documentation in the electronic health record.

• Facilitates patient access to appropriate medical and specialty providers and relevant community resources.

• Supports quality improvement initiatives related to chronic disease management and population health.

Skills and Attributes:

• Requires critical thinking skills and decisive judgment.

• Works under general supervision.

• Must be able to work in a stressful environment and take appropriate action.

• Applies more advanced skills and knowledge in the area of specialization.

Position Requirements:

Work Experience

• A minimum of 4 years’ relevant experience required

 Education

• Associate's degree or higher or Diploma in Nursing required upon hire AND

• Bachelor's degree or higher in Nursing required within 5 years of employment in this position

Licensure/Certification/Registration

• RN - Licensed as a Registered Nurse. Eligible to practice nursing in the State of Kentucky required upon hire AND

• BLS - Certified as a Basic Life Support Healthcare Provider required within 45 days of employment in this position       

Organizational Responsibilities:

• Supports Owensboro Health’s Mission, Vision, Core Commitments, and business interests.  Adheres to all organizational policies and procedures. Executes all tasks and behaves in a manner consistent with a culture of compliance, safety and a high reliability organization.

Additional Job Information:

• This job description describes the general nature and level of work required by the position. It is not intended to be an all-inclusive list of qualifications, skills, duties, responsibilities or working conditions of the job. Specific duties and responsibilities consistent with the general nature and level of work described may vary by department and additional related duties may be assigned as needed. Some duties listed may not apply to all employees with this job description. 

• The job description is subject to change with or without notice, and Management reserves the right to add, modify or remove any qualification or duty. Nothing in this job description changes the existing at-will employment relationship between the Organization and the employee occupying the position.

Standard ADA Settings:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Physical Demands:  (Office Environment)

Standing: 75%

Walking: 75%

Sitting: 50%

Lifting 0-25 lbs: 25%

Lifting 25-75 lbs: 25%

Lifting over 75 lbs: 25%

Carrying 0-25 lbs: 25%

Carrying 25-75 lbs: 25%

Carrying over 75 lbs: 25%

Pushing/Pulling 0-25 lbs: 75%

Pushing/Pulling 25-75 lbs: 50%

Pushing/Pulling over 75 lbs: 50%

Climbing: 50%

Bending/Stooping: 75%

Kneeling: 50%

Crouching/Crawling: 50%

Reaching: 75%

Talking: 75%

Hearing: 75%

Repetitive Foot/Leg Movements: 25%

Repetitive Hand/Arm Movements: 75%

Keyboard Data Entry: 75%

Running: 25%

Vision: Depth Perception: 75%

Vision: Distinguish Color: 75%

Vision: Seeing Far: 75%

Vision: Seeing Near: 75%

Hazardous Drug Risk Exposure: Low Risk

Owensboro Health Core Commitments

INTEGRITY - We conduct ourselves with a high level of responsibility, reliability and honesty because we take seriously the trust of our patients and coworkers.

RESPECT - We value and accept the unique talents and contributions of every patient, customer and team member in the Owensboro Health community.

TEAMWORK - We build a spirit of connectivity and fellowship by striving together to overcome obstacles, surpass goals, celebrate accomplishments and plan the future.

INNOVATION - We foster original ideas and creative solutions that improve our daily work and promote the mission of Owensboro Health.

SERVICE - We focus on service to patients, customers and team members by anticipating their needs, thoughtfully meeting those needs and continually improving the quality of everything we do.

EXCELLENCE - We reach beyond basic expectations to expand our knowledge and awareness, produce exceptional work and provide outstanding service.