Chronic Care Management Coordinator

Teche Health, A Federally Qualified Health Center, per Section 330 of the Public Health Service Act, is currently seeking qualified applicants for a Chronic Care Management Coordinator in Franklin, Louisiana.

JOB SUMMARY :

The Chronic Care Management Coordinator (CC M Coordinator) Provides care management for adu lt and pediatric patients with comp lex illnesses, in the primary care sett ing, under the Supervision of the Ch ro nic Disease Project Manager. In partnership with the primary care practice l eadership team, the CCM Coordinator leads care management within the team through process im p r ovement, workflow redesign, helping with training, and delegating to other members of the team. Serves in an expanded health care role to collaborate with specialists , members of health care team, and patients/fami l ies to ensure delivery of quality, eff icien t , and cost-effective health care serv ic es. Assesses plans, implements, coordina te s, monitors, and eva lu ates a ll options a nd services with the goa l of optimizing the patient's health stat u s . Int egrates evidence-based clinical guidelines, preventive gu id el in es, and protocols, in the deve l opment of i ndividualized care plans that are patient-centric, promoting qua li ty and efficiency in the de l ivery of health care. Provides other duties as assigned by Chronic Disease Project Man ager .

Prov i des targeted i nterventions to avoid hospital i zation and emergency room visits. Coordinates care across settings and helps patient/fam i l i es understand h ea lth care options.

JOB DUTIES AND RESPONSIBILITIES :

1. Identifies the targeted CCM population within pr actice site(s) per primary care provider (PCP) referr al, risk strati fi cation, and patient lists. Includes patients with repeated s o cial a nd/ or health crises.

2. Assesses over time the health care, e du cational, and psychosocial needs of the patient/fami l y. Uses standardized assessment too l s such as depression screeni n g, functionality, and health ri sk assessment.

3. Collaborates with PCP, patient, and members of the health care team, including continuum of care sett ings an d community. Responsible for d eveloping a comp r ehe n s ive individua l ized plan of ca r e a nd targeted interventions. Continua ll y monitors patient/family re spo n se to plan of care and revises the care pl a n as indicated.

4. Provides patient se l f- management support with a focus on empowering the patient/family to build capacity for self-care.

5. Implem ents system of care that facilitate close mon i toring of high-r i sk patient s to prevent a nd/ or intervene ear l y during acute exacerbat i ons.

6. Implements clinical interventions and protocols based on risk stratification and evide nc e-based clinical guidelines .

7. Coord inat es patient care through ongoing co ll abora tion with PCP , patient/family, community, and other members of the health care team. Fosters a team a pproa c h and includes patient/family as active members of the team. Takes the lead in ensuring the con t inuity of care which extends beyond the practice bound aries. Serves as liai so n to acute care hospitals, specialists, and post-acute care services .

8. Provides follow-up with pat i ent/family when p at i ent transitions from one setting to another. Completes t imely post-hospita l fo ll ow-up: Medication reconciliation, PCP, or spe cia l ist follow-up appoi ntm ent, assess symp tom s, teach warning signs, revi ew discharge in struct ions, coordi n ation of care, and problem solve barriers.

9. D emo nstrates excellent written, verbal, a nd l i ste ning communication skills, positive relationship building ski ll s, and critical analysis skills .

10. Mainta i n s requ i r ed documentation for all c a r e m a nag e m e nt activities.

11. Works with facility leadership to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance care management and Patient Centered Medical Home delivery of care model.

12. Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates into clinical practice.

13. Participates/Reports in Quality Assurance Performance Improvement (QAPI) Committee.

14. Oversees the patient evaluation data and makes recommendations to team members accordingly.

15. Performs other duties as assigned by the Chronic Disease Project Manager.

SKILLS AND ABILITIES

1. Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.

2. Demonstrates ability to work autonomously and be directly accountable for practice.

3. Demonstrate ability to influence and negotiate individual and group decision-making.

4. Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment.

5. Demonstrates leadership qualities including time management, verbal, and written communication skills, listening skills, problem solving, critical thinking, analysis skills and decision-making, priority setting, work delegation, and work organization.

6. Demonstrates 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.

License Practical Nurse (LPN).

Two years of experience with adult medicine and pediatric patients in primary care/ambulatory care, home health agency, 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 skills and ability to analyze complex data sets. Ability to manage complex clinical issues utilizing assessment skills and protocols.

Excellent assessment and triage and medication management skills. Ability to implement evidence-based interventions and protocols for chronic conditions.

Demonstrates excellent communication - both verbal and written.

Excellent interpersonal and facilitation skills.

Ability to affect change, work as a productive and effective team member, and adapt to changing needs/priorities.

Time management, priority setting, work delegation, and work organization.

General computer knowledge and capability to use computers

Care management experience (preferred)

Experience as participant in continuous quality improvement (preferred)

Completion of self-management support training (preferred)

- Ability to organize and integrate organizational priorities and deadlines

- Ability to work harmoniously with professional and non-professional personnel

- Ability to seek out new methods and principles and be willing to incorporate them into existing practices

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

- 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 applying for. Internal applicants must be with 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 will be 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.**