Chronic Care Manager

Chronic Care Manager

Location: Remote after training period

Job Type: Full-time

Company: MedLink Georgia

About Us:

MedLink GA is a leading healthcare provider dedicated to delivering high-quality, patient-centered care across Georgia. We are seeking someone who is compassionate and detail-oriented to join our team and support healthcare professionals in providing top-notch medical services to our community.

Responsible for facilitating care coordination services for Medicare Chronic Care Management enrolled patients. The Coordinated Care Manager displays thorough knowledge of Medicare Chronic Care Management program requirements. The Coordinated Care Manager ensures that eligible patients receive timely, high quality and efficient health care and support services and acts as a guide and advocate for Chronic Care Management enrolled patients and their families. The Coordinated Care Manager is very familiar with community resources and referral sources. The Coordinated Care Manager may also serve as a referrals coordinator for the center that is served. As a recognized patient-centered medical home (PCMH), every employee is responsible for ensuring the successful implementation of quality, comprehensive patient-centered care as a member of the patients care team. By performing the job expectations described below you will be an active member of the care team thereby patients are assured access to team-based, coordinated, comprehensive, quality care.

ESSENTIAL DUTIES AND RESPONSIBILITIES (include, but are not limited to, the following)

Pre-Visit Planning:

• Working with the Provider, Practice manager, Practice Site Supervisors, Medical Secretaries, and Clinical Staff, and utilizing internal and external data sources, identifies patients eligible for Chronic Care Management (CCM) services.
• Reviews provider schedules and identifies list of patients who may be eligible for CCM services as well as those already enrolled. Provides this information to staff during morning huddles.
• Prints visit summaries from CCM eligible identified patients and scrubs for gaps in care (i.e., immunizations, required lab work, other preventive care needs). Notes these needs in EMR.
• If lab/diagnostic imagining or specialist referral is noted on the visit summary, obtains results if not in EMR.
• Obtains reports if reason for visit is noted as hospital or emergency department follow up.

For CCM enrolled patients:

• Obtains informed consent from patients prescribed CCM by the provider
• Reviews the medical record to determine care plan ordered by the provider
• Provides copy of care plan to patient
• Calls patients at least monthly to identify potential barriers in care and needed follow up. Talks with patients to understand their needs.
• Helps patients understand their condition and treatment options. Provides education and literature about their diagnosis.
• Reviews treatment goals with patients.
• Coordinates the integration of CCM functions with providers and other services.
• Communicates with provider regarding patient's plan of care.
• Identifies and links patients with community resources to facilitate referrals and respond to social service needs.
• Track and support CCM enrolled patients when they obtain services outside the practice such as Emergency Departments, Hospitals, specialist offices, and other health care facilities.
• Follow up with patients within a few days of an emergency room visit or hospital discharge
• Under the direction of providers, communicate test results and care plans to patients and families.
• Provide relevant self-management support for enrolled patients
• Assist patients with the process of determining eligibility, obtaining and maintaining free pharmaceuticals through the Patient Assistance Program.
• Manage referrals, when needed, to appropriate agencies required to assist the client in achieving goals and objectives identified in their care plan
• Be the system navigator and point of contact for patients and families, with patients and families having direct access for asking questions and raising concerns.
• Assist patients in problem solving potential issues related to the health care system, financial or social barriers
• Assists with collection and documentation of enrolled patient Quality Measures in EMR.
• Provides information to the patient that is culturally and linguistically appropriate.
• Works with the Director of Revenue Cycle Management and the Revenue Cycle Team to ensure accurate billing of CCM services
• Ensures that all CMS CCM Scope of Service requirements are fulfilled, including:
  • Structured recording of demographics, problems, medications, medication allergies, and the creation of a structured clinical summary record in the EHR
  • 24/7 access to care management services
  • Continuity of care with a designated member of the care team
  • Systematic assessment of health needs and receipt of preventive services (including assessment of medical, functional, and psychosocial needs; systems based approaches to ensure timely receipt of all preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of patient self-management of medications)
  • Creation/maintenance of a comprehensive plan of care for all health issues that is patient-centered, based on a physical, mental, cognitive, psychosocial, functional and environmental assessment or reassessment
  • Management of care transitions, including creation/formatting clinical summaries according to CCM certified technology and transmission/exchange of summary care record using any electronic tool other than fax
  • Coordination with home and community-based clinical service providers as appropriate, with communication to and from these providers documented in the HER
  • Enhanced communication opportunities for patient and caregiver through telephone, secure messaging, secure internet or other asynchronous non face-to-face consultation methods, subject to HIPAA
  • Informed consent, including informing that cost share applies

General Duties and Responsibilities

• Establishes and maintains relationships with identified service providers and community resources
• Demonstrates excellence in both internal and external customer service
• Understands and effectively communicates HIPAA compliance, corporate compliance and client confidentiality
• Ensures compliance with local, state, and federal regulations
• Serves as a resource for center staff for CCM guidelines
• Educates center staff about CCM guidelines and services utilizing a variety of delivery methods

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Reads, speaks, understands and writes proficiently in English.
• Effectively communicates orally and in writing.
• Ability to effectively and professionally represent the organization.
• Requires working knowledge of MS Office products.
• Works independently and is self-directed.
• Requires excellent verbal and written communication skills.
• Knowledge of the Health Insurance Portability and Accountability Act (HIPAA)
• Ability to work in a team environment.
• Organizes, priorities, and coordinates multiple activities and tasks.
• Applies skills in employee relations.
• Remains calm and effective in high pressure and emergency situations.
• Proficiency in the use of Electronic Health Record Practice Management Software/Systems, Microsoft Office applications; Word, Excel, Power Point and Outlook.
• Thorough knowledge of community resources and needs assessment information.
• Ability to establish positive relationships with co-workers, professional staff and management.
• Sound interpersonal skills and the ability to interface with all levels of staff and management.
• Ability to establish and maintain relationships with employees, elected and other government officials, members of neighborhood organizations, social and medical professionals and the general public.

EDUCATION and/or EXPERIENCE

Licensed Practical Nurse Degree or Medical Assistant Certification. One year of experience/exposure to medical records.