Chronic Care Management (CCM) Nurse

Job Status: Full Time

FLSA Status: Non-Exempt

Reports To: CCM Director

Grade/Level: Associates or bachelor’s degree in Nursing

Amount of Travel Required: minimal

Work Schedule:

• 8 a.m. to 5:30 p.m. Monday - Thursday.
• 8 a.m. to 12:00 p.m. on Friday.
• However, additional hours may be required to complete duties as applicable.

POSITION SUMMARY:

The Chronic Care Management (CCM) Nurse works as part of the care team, assisting providers in offering health education, chronic disease management and preventative services to the patient population. The CCM Nurse will work closely with all members of the care team to achieve system goals of improving clinical outcomes for patients with chronic diseases; developing processes that support the CCM program and ensuring all requirements have been met to bill and receive reimbursements that support the program for continued growth. The CCM Nurse is involved in continuous Quality Improvement practices and measures as set by Mainline Health Systems, Inc. and in which the practice focus is based on a Patient Centered Medical Home model of care.

SPECIFIC DUTIES AND RESPONSIBILITIES:

• Manage a caseload of assigned panel of patients who meet clinical requirements for Chronic Case Management (CCM).
• Meet production and department goals for the CCM program.
• Develop and maintain comprehensive and holistic care plans for the assigned caseload.
• Complete monthly phone calls to patients of the assigned caseload to review individual care plans, progress, and compliance.
• Collaborates with all members of the care team in identifying appropriate patients for care management.
• Develops relationships with patients as an integral member of their care team.
• Provides follow-up management with patients to ensure compliance with their individual care plan.
• Promotes patient self-management and empowers patients/families to achieve their care goals.
• Determines and assists with appropriate referrals as needed.
• Collaborates with the patient, providers, and care team in assessing the patient’s progress toward their individual health care goals.
• Maintains accessible, consistent documentation of patient self-management measures, and reporting progress towards goals.
• Assists patients in setting SMART goals for self-management, teaching them how to do self-management tasks, and reports abnormal findings to their provider and care team.
• Assesses barriers when patient has not met treatment goals, is not following the treatment plan, or has not kept appointments.
• Promote customer-driven excellence as a driver of organizational services and goals.
• Performs all job duties in compliance within MHSI policies and procedures and HIPAA.
• Participates in all Risk Management activities, and report to QI as needed or deemed appropriate.
• Other duties as assigned.

SKILLS & ABILITIES:

Education

Associates or bachelor’s degree in nursing

Experience

Minimum 1- year experience in Chronic Case Management preferred

Certificates & Licenses

Current licensure as an LPN or RN in the State of Arkansas.

REPORTING RELATIONSHIP:

The CCM Nurse reports to, is supervised, and evaluated by the CCM Manager.

EVALUATION:

The evaluation of work performance will be ongoing, and will be carried out by the CCM Manager. It will include specific duties and responsibilities of this position description plus employee attitude and general working behavior. Formal evaluation will be performed annually, but may be initiated at other times by the CCM Manager.

STATUS:

This is a FLSA Non-Exempt position.

This is an OSHA low risk position.

DISCLAIMER

The duties and responsibilities, qualifications, physical conditions and other statements contained herein represent the current general nature of the job described, and are subject to change at any time, with or without notice. This job description does not limit in any way the assignments that may be given to an employee in the job, and employees are expected to perform any and all duties assigned by their supervisor willingly and without reservation.