*** Position is based onsite in our Care Center in Augusta, Georgia ***
Job Description Summary:
The Chronic Care Management RN is responsible for the oversight of patient-centered care coordination for up to 10,000 patient lives receiving Chronic Care Management (CCM) and Transitional Care Management (TCM). The CCM RN assures all CCM and TCM service elements are met, documented and coordinated.
Essential Job Functions/Responsibilities:
A. Responsible for the coordination of Medicare, Medicaid and private insurance beneficiaries’ care, assuring the required elements of CCM and TCM are met. Oversees the coordination and facilitation of care transitions. Supervises Medical Assistants which are responsible for receiving patient data and enrolling patients for the appropriate service(s).
B. Provides clinical expertise and oversight for chronic care management of patients. Acts as a resource to others.
C. Documents all communication and coordination of patient contact in electronic documentation system including aggregation and clinical summaries. Assures documentation includes tracking and time-stamping to support billing for CCM and TCM.
D. Completes and answers patient calls related to CCM/TCM activities.
E. Is proficient in the use of the electronic documentation. Provides consultative support and training to staff in required elements, documentation and coordination.
F. Assures the electronic comprehensive care plan is created and maintained accurately per Medicare Regulations and organizational policies and procedures.
G. Establishes and maintains positive relationships with all internal and external customers. Acts as a liaison for assigned patients with client (physician office, facility, etc.).
H. Responds to customer requests and concerns. Documents all concerns and follow-up and escalates to Director when appropriate.
1. Registered Nurse licensed in the state of Georgia required. Multi-state license strongly preferred, License must be unencumbered and must have the ability to apply for nursing licensure in multiple states.
2. Possesses and maintains current CPR certification.
3. Knowledgeable in the Medicare benefit for CCM and TCM.
4. 2 years’ experience in the care or case management of patients with chronic conditions or similar setting.
5. Bilingual/Spanish-speaking highly desirable
6. Risk stratification and population health experience are a plus.
7. Experience with a variety clinical systems and ability to quickly master new IT systems.
8. Proficiency in Microsoft Office applications.
9. Adaptability to work with various disciplines in multiple locations (i.e. NavCare Call Center, physician office, facility).
10. Must be able to work in a seated position for extended periods of time.
11. Must be well organized with an ability to set priorities and use time effectively.
11. Excellent communication, leadership and customer service skills.
12. Flexibility to handle a workload that fluctuates greatly based on team needs.