Chronic Care Management-Nurse (RN, LVN, Paramedic)

Job Description:
This role will be providing telephone Chronic Care Management for patients throughout the health system
under the direction of the patient’s physician.
Utilizes nursing process to evaluate patient needs over the telephone and provide guidance and education
to patients, adhering to organizational policies, procedures and guidelines. Provides high risk patients
with chronic disease management and liaises between the patient, hospital, physicians’ office, home care
agency, etc. This position is telephonic care coordination as directed by the patient’s physician.

Job Responsibilities
• Assess client’s needs for services and cooperatively develop an integrated patient centered care plan and goals with the client/family and other providers.
• Coordinate transitional care from an inpatient service to other settings as per care plan.
• Work collaboratively with team members to provide outreach and engagement.
• Provide assistance through advocacy to client and family for entitlements and other community services
• Work closely with in-office providers to manage the day to day calls involving: symptom control, medication management, and provide patient and family education.
• Receive triage and respond to telephone calls from patients requiring medical guidance.
• Provides patients with clear instructions and education utilizing appropriate guidelines.
• Educates the patient on properly contacting physician office for urgent care matters / or 911 when appropriate or unsure.
• Directs patient to keep follow-up appointments with physician office and to maintain self-home care based on physician direction and outcomes of nursing assessment.
• Utilizes the in-office staff, and Clinical Call Center to meet the needs of the patient and family.
• Documents calls according to established guidelines.
• Communicates with physician, Nurse Practitioner, RN, Social Worker or other health care providers regarding patient’s status.
• Collaborates with the Nurse Practitioner, and or physician when patient requires intervention or follow-up.
• Participates in education and in-service programs. 


Knowledge and Skills
• Graduate from an accredited School of Nursing.
• Current license to practice as an LVN/LPN in current state with at least 3 years as an LVN.
• Minimum of 3 years’ experience as a Care/Case Manager or Coordinator either in the homecare, inpatient, physician practice or in-home case management setting.
• Experience working with the adult population
• Ability to work a full-time (40 hours minimum)
• Prefer experience working as telecommuter or call center setting.
• Experience in clinical telephone triage
• Experience working with Electronic Health Record (EHR)
• Demonstrates progressive proficiency with the utilization of available computer technology, including typing skills.
• 60 + WPM typing
• Demonstrated customer service, leadership, communication, interpersonal and problem-solving skills, required.