Chronic Care Coordinator Nurse (Healthcare)

The Chronic Care Coordinator Nurse is responsible for the care management of chronically ill patients with chronic diseases such as but not limited to chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, and or congestive heart failure. They will be responsible for the registry of chronic care management (CCM) patients. They will validate enrollment of CCM patients based on provider request and comply with documentation requirements of the CCM program by carrying out the care plan with the patient, family/caregiver(s) and providers and recording in the EHR. They will monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed. They will collaborate with team members to identify care needs as directed as well as underdeveloped care needs. Be versed in patient education and pre-and-post care instructions to patients in direct correlation to provider orders and defined plan of care. The duties, responsibilities, and activities may change at any time with or without notice.
Duties/Responsibilities:
Develop and establish a working relationship with multiple departments to ensure cohesive communication, direction, and completion.
Validates enrollment of CCM patients based on provider request.
Conducts a minimum of one 20-minute telephone or in-person counseling and education per month to each CCM patient on roster.
Creates and ongoing process for patient and family/caregiver(s) to determine and request the level of care coordination support they desire.
Work closely with office providers to manage the day-to-day calls involving symptom control, medication management, and providing patient and family education.
Educates patient and family/caregiver(s) about relevant community resources.
Assist with the identification of high-risk patients (the chronically ill and those with special health care needs) and assist on the enrollment of these to the patient registry.
Coordinates continuity of patient care with external healthcare organizations and facilities including from the primary care provider to a specialty care provider.
Provides patient health counseling, education, and instruction.
Review patients medical, functional, and psychosocial needs.
Medication reconciliation with review for adherence.
If labs are indicated, contact patients for further instructions and preparations. Follow up and close any open orders or referrals. Assemble reports for provider.
Notify patients of lab results, changes in provider orders, specialist appointments, and document notification in EHR.
Facilitate patient follow-up visits with PCP for acute or chronic needs.
Documents concerns and follow-up and escalate to PCP when necessary.
Review care standards to evaluate effectiveness of quality as indicated.
Attend workshops and seminars as necessary to increase skills and knowledge to provide effective care, treatment, and leadership.
Support program development and outreach activities as needed.
Adheres to the facilitys Standard of Excellence.