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Clinical Triage / Chronic Care Management (CCM) Nurse
Job
Coalfield Health Center
Chapmanville, WV (In Person)
$39,510 Salary, Full-Time
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Job Description
Job Overview We are seeking a dedicated and energetic Clinical Triage / Chronic Care Management (CCM) Nurse to join our dynamic healthcare team. In this vital role, you will serve as a frontline responder, providing expert clinical assessment and management for patients with complex, chronic conditions. The Clinical Triage / CCM Nurse (LPN) is responsible for clinical triage, chronic care management, patient education, care coordination, hospital follow-up, and communication with patients, providers, and community partners. This position serves as an extension of the provider team to improve continuity of care, patient engagement, and health outcomes. The nurse works closely with the Quality Nurse to identify opportunities for improving patient care, closing care gaps, coordinating preventive services, and enhancing patient outcomes while maintaining compliance with organizational policies and clinical standards. Responsibilities Perform clinical triage and prioritize patient needs appropriately. Prepare patients for examinations and assist providers during treatment and procedures. Handle patient telephone calls regarding medications, test results, and treatment instructions as directed by providers. Complete prior authorizations and assist with referral coordination as needed for continuity of patient care. Track referrals, hospital discharges, and follow-up appointments. Coordinate Medicare Annual Wellness Visits and Welcome to Medicare Visits. Develop and maintain chronic care management plans. Provide monthly chronic care outreach and wellness calls. Educate patients regarding chronic disease management, medications, preventive care, and self-management strategies. Coordinate care among providers, hospitals, home health agencies, specialists, and community resources. Maintain accurate documentation in the Electronic Health Record. Assist with vaccine clinics, outreach activities, and patient education programs. Monitor high-risk patients and facilitate appropriate follow-up care. Ensure infection control, OSHA compliance, and patient safety standards. Work closely with the Quality Nurse to improve patient outcomes, coordinate preventive services, identify care gaps, and support quality improvement initiatives. Provide clinic coverage for peer absences and float between locations as needed. Other duties as assigned.