Job Summary
Manages and coordinates services for patients who have identified health needs. Assists with the coordination and management of care for these patients in the community and practice setting with the assistance of a multidisciplinary team.
Evaluate, write, and implement a patient’s care plan in collaboration with the team. Identify, and track patients in EMR that would qualify for CCM program.
Supports other Chronic Care team members and Quality Coordinator with notes to provider. Check progress, eligibility, and status of patient and communicate if they have been moved to home health services or discharged from the hospital to provider.
Each week review monthly chronic care management tracking time for all patients and submit claims if eligible. Patient load should be 100 to 120 per Consistency with all patients & have good communication written and verbal.
Partner with all areas of clinic, home health, and hospital. Comfortable operating computer system and CCM software. Stay up to date on billing and reimbursement requirements for CCM.
Job Requirements
- Minimum Education Requirement Registered Nurse or LPN
- Minimum Experience Requirement Minimum of one year of case management or community health experience required. Must have organizational, verbal and interpersonal skills.
Must have advocacy skill, knowledge of community resources and data management and documentation. Must be able to successfully work alone or collaboratively with a team of professionals.
- Minimum License Requirement Licensed to practice as a Registered Nurse or an LPN in State of South Carolina in good standing.
- Physical Requirement / Working Conditions External applicants, as well as position incumbents who become disabled, must be able to perform the essential functions, either unaided or with the assistance of a reasonable accommodation to be determined on a case by case basis.
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