Chronic Care Management - CMA or LPN

Job Category:

Clinical Location:

Blakely Travel Required:

Varies Level/Salary Range:

Competitive based on

Experience Position Type:

Non-Exempt Reports to: Chronic Care Manager Job Summary The Chronic Care Management CMA or LPN is part of our patient Care Team. The CCM's primary responsibility is to provide telephone chronic conditions care management for the patient or caregiver of Primary Care of Southwest Georgia. Responsibilities include, but are not limited to, triaging, coordinating, documenting, communicating, and tracking of CCM patient calls, cases and records. The goal of the CCM is to facilitate care between provider visits in order to obtain the patient's best outcome, prevent complications, prevent hospital readmission, and/or prevent repeated emergency room visits. Duties/Responsibilities Initiate phone calls to patient or assigned caregiver at least monthly to manage/monitor care with the sum of the monthly interactions to accumulate no less than 20 minutes per patient per calendar month Assess client's needs for services and cooperatively develop an integrated patient centered care plan and goals with the patient/family and other providers. Assist with ongoing patient needs and manage internal/external referrals to other providers Assist patient and family for entitlements and other community services, including transportation Work collaboratively with the Care Team and other facility members to provide outreach and engagement Work closely with providers and care team to manage incoming calls involving symptom control, medication management, and appointment scheduling Provide patient and/or family with clear instructions and education on chronic conditions Act as the main point of contact for the patient and ensure coordination, follow-up, and continued engagement with the Care Team. Educate the patient on contacting PCSG for non-emergent concerns and when to contact 911 Respond to incoming calls/voicemails and conduct outgoing calls between recurring visits to identify and proactively address emerging issues. Contact and assess patients following an ER or inpatient hospital visit, coordinate transitional care, and facilitate follow-up with PCP. Ensure and direct patients to keep follow-up appointments while assessing met CDSS measures Establish, retain, and grow strong relationships with patients Communicate with other health care providers regarding patient's status Utilize resources to meet the needs of the patient and/or caregiver Provide written and verbal educational material regarding patient's chronic conditions, treatment, medication, and care plans Participate in continuing education and in-service programs Maintain strict confidentiality following HIPAA regulations Other duties as assigned or modified Competencies Excellent work ethic Self-motivated and self-directed Professional demonstration promoting values of PCSG Excellent verbal and interpersonal communication skills Clinically strong knowledge of chronic diseases Excellent customer service skills Required Skills & Abilities Certified Medical Assistant or Licensed Professional Nurse 2+ years of employment as a Medical Assistant (recent clinical experience) preferred Graduate from a nationally accredited Medical Assistant program such as

AAMA, AMT

(RMA), or

NCQT. BLS

Certified or willing to become certified within 6 months of employment. Physical Demands Prolonged periods of sitting at a desk and working on a computer. Ability to lift at least twenty pounds at times.

Job Type:

Full-time Benefits:

Dental insurance Disability insurance Employee assistance program Health insurance Life insurance Paid time off Retirement plan Vision insurance

Experience:

medical/clinical: 1 year (Required)

License/Certification:

BLS Certification (Required) Georgia CMA or LPN license (Required)

Work Location:

In person