**Job Description: **The Care Management Nurse Care Coordinator is responsible for coordinating patient care for the enrolled patients in the Care Management Call Center. Coordination includes patient calls, establishing patient goals and review of goals on a monthly basis with the patient.
Essential Functions: In addition to working as prescribed in our Performance Factors specific responsibilities of this role include:
- Facilitate and obtain patient contracts and meet with eligible patients to explain CCM and the enrollment contract.
- Initiate and document on the Care Plan in the clinical medical record for each chronic disease
- Establish goals for each chronic condition for each patient
- Review medications (over the counter and prescribed) and ensure they are being taken as directed.
- Arrange physician appointments
- Document a minimum of 20 minutes/month contact with patients in their case load.
- Complete billing documentation for each patient monthly
- Report to the CCM Manager if more assistance is needed for complex cases.
- Excellent communication (written and oral) and interpersonal skills.
- Strong organizational, multi-tasking, attention to detail, and time-management skills.
- Proficient computer skills
- Must be able to act both independently and as a team member.
- Minimum of two years’ experience in nursing care or other clinical areas such as home health, nursing home, skilled nursing unit, unit clerk or in a department of an acute care facility.
- Exhibit knowledge and of clinical document requirements of care plans, medical terminology, HIPAA, and knowledge of chronic diseases
- Effectively demonstrate compassion and communicate with elderly patients with chronic illness
- Knowledge and skills necessary to meet individual needs based on physical, psycho-social, educational, safety and other criteria appropriate for each individual patient
- Occasional travel (25% or Less)
- Work in a seated position and read a computer screen for prolonged periods of time
- Flexibility to handle a workload that fluctuates and grows with time
Education/ Certification Requirements
- Current license as an LPN, and ability to be licensed in all states
- High school diploma or equivalent