Practice seeks candidates for medical position(s); Chronic Care Management Specialists (CCMS) staff maintain a crucial client advocacy role within our healthcare team. This is a part-time hourly position. This is a dynamic role that is clinical/logistical/motivational and assures optimal patient outcomes as they relate to chronic medical conditions as stipulated by the Centers for Medicare and Medicaid Services's (CMS) Chronic Care Management Services program for Medicare recipients. CCMS's provide clinical support within the program to include troubleshooting of insurance for denial of acquisition of any medical needs, care plan creation and management, medication reconciliation, and patient medical education and coaching. Moreover, CCMS's are assigned a patient panel as the point person, ensuring all assigned client's healthcare prevention and quality are provided in a superior fashion throughout their care and to outside services.

Duties:

CMS's basic tenets of the program include: Structured recording of patient health information, maintaining comprehensive electronic care plans, managing care transitions and other care management services, and coordinating and sharing patient health information promptly within and outside the practice. The CCMS will provide services outside of face-to-face visits for advanced primary care processes such as continuous patient relationship with a chosen care team member, supporting the patient with a chronic disease in achieving health goals, 24/7 patient access to care and health information, patient getting preventive care, and patient and caregiver engagement prompt sharing and using patient health information. Specifically, the CCMS ensures prior consent for the program has been received, the initiating visit is completed/documented, and the care plan is made available to the patent or caregiver; additionally, this information is reflected in the Electronic Health Record (EHR) CCM function. CCMS complete/edit/monitor the clinical care plan and obtain provider approval prior to use or after changes, records patient demographics, problems, specialists, and medications and allergies in the EHR. The patient and/or caregiver must receive a copy of the approved care plan. Approved care plans are electronically captured and made promptly available to people involved in the patient's care, as appropriate. Comprehensive care plans should include, but are not limited to: a problem list, expected outcome and prognosis, measurable treatment goals, cognitive and functional assessment, symptom management, planned interventions, medication management, environmental evaluation, caregiver assessment, interaction and coordination with outside resources, practitioners, and providers, requirements for periodic review, and when applicable, revision of the care plan. The CCMS then manages comprehensive care.

This should routinely include:

Assess the patient's medical, functional, and psychosocial needs, make sure the patient gets timely recommended preventive services, review medications and any potential interactions, oversee the patient's medication self-management, coordinate care with home- and community-based clinical service providers, communicate with home- and community-based providers about the patient's psychosocial needs and functional decline, and document it in the patient's medical record. Given the serious and often detrimental outcomes associated with transitions between and between and among healthcare providers and settings, transitional care management is highly desirable. CCMS can additionally, manage referrals to other clinicians, or following up after an emergency department visit or after discharges from hospitals, skilled nursing facilities, or other health care facilities, and creating and exchanging or sharing continuity of care documents promptly with other practitioners. The CCMS will need to easily navigate computer data entry, scan/fax/copy/email forms/documents, assist in Electronic Health Record (EHR) management and records release/transfer, utilize phone system, and communicate efficiently and effectively with all types and levels of healthcare staff, providers, and medical supply entities.

Experience:

Clinical Staff (MA, EMT, CNA, GNA, X-Ray Tech, LPN): 1 year (Required)

Education:

High school or equivalent (Required)

Current Certification/Licensure/Training:

Clinical Staff (per type) for the state of Maryland.

Pay:

$15.00 - $30.00 per hour

Benefits:

Paid time off Application Question(s): Are you located in, or close to, Frederick County, Maryland? What is your comfort level calling patients and family members on the phone?

Work Location:

Hybrid remote in Frederick, MD 21701