Pinner Clinic, PA
Job Description
Job Description The CCM Coordinator will have the responsibility of managing and conducting the CCM initiatives and activities of Pinner Clinic to promote improved health outcomes for patients with chronic conditions. This position requires phone interaction with patients to conduct chronic care management, act as a liaison between the patient and the provider (and when necessary to hospitals, specialists, and home care agencies), and, when able, telephonically address gaps in care under the direction of the patients medical provider. The CCM Coordinator will utilize the nursing process to evaluate patient needs over the telephone and provide guidance and education to patients, adhering to organizational policies, procedures, and guidelines.
Minimum (REQUIRED) Qualifications:
Current license from an accredited school to practice as an LPN in South Carolina or a Certified Medical Assistant More than five years experience working as a licensed nurse or certified medical assistant Experience with adult and Medicare population Appreciation of diversity and sensitivity towards targeted populations Able to interact effectively and in a supportive manner with persons of all backgrounds
Job Specific Functions:
In collaboration with and under the direction of the patients provider, conduct patient outreach by telephone to provide education and coordinate care for preventive and chronic disease management, address patient gaps in care and fulfill
regulatory/contractual
requirements with payers. Assess clients needs for services and cooperatively develop an integrated patient centered care plan and goals with the patient/family and providers. Provide a copy of the care plan to the patient. Assist with
referring/connecting
patient to appropriate ancillary services such as payer specific CM/DM programs, pharmacist support, and other resources as identified. Assist with managing high-cost and/or high-risk populations that include, but are not limited to, specific chronic diseases, high ER utilizers, medication compliance, and other identified areas of focus. Administer screening tools (i.e., alcohol and depression) according to practice standing orders and what can be accomplished by phone. Document all communication with patient and family members according to established guidelines in the practice EMR. Communicate with Physician, Nurse Practitioner, and other health care providers regarding patients status. Help ensure that the patients medical record is up to date with information on specialist referrals, consults, hospitalizations, ER visits and other resources being used related to their health. Filter CCM lists/reports inside the Dulcian Health CCM app used by the practice and give to teams weekly to promote ongoing clinical care and follow up efforts. When requested, assist with scheduling patients due for Medicare Annual Wellness Visits. When requested, conduct pre-visit planning/chart review for Medicare patients at least 24-48 hours prior to the scheduled Medicare Annual Wellness Visit. Ensure all needed medical records are available to provider prior to patients Medicare Annual Wellness Visit. Support patients and families in self-management, self-efficacy, and behavior change. Communicate with patients and families in an effective, patient-centered manner. Coordinate with other team members to provide exceptional patient service. Maintain strictest confidentiality, adhering to all HIPAA guidelines and regulations.
Job Description The CCM Coordinator will have the responsibility of managing and conducting the CCM initiatives and activities of Pinner Clinic to promote improved health outcomes for patients with chronic conditions. This position requires phone interaction with patients to conduct chronic care management, act as a liaison between the patient and the provider (and when necessary to hospitals, specialists, and home care agencies), and, when able, telephonically address gaps in care under the direction of the patients medical provider. The CCM Coordinator will utilize the nursing process to evaluate patient needs over the telephone and provide guidance and education to patients, adhering to organizational policies, procedures, and guidelines.
Minimum (REQUIRED) Qualifications:
Current license from an accredited school to practice as an LPN in South Carolina or a Certified Medical Assistant More than five years experience working as a licensed nurse or certified medical assistant Experience with adult and Medicare population Appreciation of diversity and sensitivity towards targeted populations Able to interact effectively and in a supportive manner with persons of all backgrounds
Job Specific Functions:
In collaboration with and under the direction of the patients provider, conduct patient outreach by telephone to provide education and coordinate care for preventive and chronic disease management, address patient gaps in care and fulfill
regulatory/contractual
requirements with payers. Assess clients needs for services and cooperatively develop an integrated patient centered care plan and goals with the patient/family and providers. Provide a copy of the care plan to the patient. Assist with
referring/connecting
patient to appropriate ancillary services such as payer specific CM/DM programs, pharmacist support, and other resources as identified. Assist with managing high-cost and/or high-risk populations that include, but are not limited to, specific chronic diseases, high ER utilizers, medication compliance, and other identified areas of focus. Administer screening tools (i.e., alcohol and depression) according to practice standing orders and what can be accomplished by phone. Document all communication with patient and family members according to established guidelines in the practice EMR. Communicate with Physician, Nurse Practitioner, and other health care providers regarding patients status. Help ensure that the patients medical record is up to date with information on specialist referrals, consults, hospitalizations, ER visits and other resources being used related to their health. Filter CCM lists/reports inside the Dulcian Health CCM app used by the practice and give to teams weekly to promote ongoing clinical care and follow up efforts. When requested, assist with scheduling patients due for Medicare Annual Wellness Visits. When requested, conduct pre-visit planning/chart review for Medicare patients at least 24-48 hours prior to the scheduled Medicare Annual Wellness Visit. Ensure all needed medical records are available to provider prior to patients Medicare Annual Wellness Visit. Support patients and families in self-management, self-efficacy, and behavior change. Communicate with patients and families in an effective, patient-centered manner. Coordinate with other team members to provide exceptional patient service. Maintain strictest confidentiality, adhering to all HIPAA guidelines and regulations.