Chronic Care Manager, RN Part-time
- Identify and enroll eligible patients in Chronic Care Management and other appropriate care-management programs.
- Perform comprehensive nursing assessments and identify medical, psychosocial, medication and safety-coordination needs.
- Conduct scheduled telephone and/or electronic follow-up with patients regarding chronic conditions, medications, symptoms, treatment plans, appointments and healthcare goals.
- Monitor patient progress and communicate significant changes in condition to the appropriate providers.
- Coordinate transitions of care following emergency department visits, hospitalizations, skilled nursing stays, and specialist visits.
- Review hospital discharge information and assist patients with follow up appointments medication reconciliation, and implementation of discharge instructions.
- Identify barriers to care, including transportation, medication affordability, health literacy, and social needs, and connect patients with appropriate resources.
- Track monthly CCM activity and assist in ensuring documentation supports appropriate billing and reimbursement.
- Maintain timely, accurate, and complete documentation of patient contacts, interventions, care-plan updates, and time spent providing quality care.
- Coordinate referrals and communication among primary care providers, specialists, pharmacists, home health agencies, hospitals and other healthcare organizations.
- Maintain patient confidentiality and comply with HIPAA, CMS, Rural Health Clinic, organizational, and DNV standards.
- Communicate routinely with providers regarding high-risk patients and patients whose condition requires additional evaluation or intervention.
- Educate patient and caregivers regarding chronic disease management, medication, diet, lifestyle modifications, warning signs and when to seek medical attention.
- Perform other nursing duties and care coordination duties as assigned within the RN’s scope of practice.