Job Description

Chronic Care Management Nurse

The primary objective of this role is to enhance patient outcomes through effective chronic care management while driving improvements in departmental quality metrics. Key focus areas include optimizing Medicare Wellness visit compliance, closing patient care gaps, and ensuring timely completion of transition of care processes, including hospital follow-up coordination.

Responsibilities include scheduling Medicare Wellness Visits in compliance with frequency guidelines set by CMS and individual insurers. Scanning upcoming appointments for additional medical record information necessary. Obtaining medical records from other physician offices, hospitals, labs, emergency rooms, and radiology departments prior to or following patient visit. Following chronic disease and preventive care guidelines and ensuring that appropriate plans for completion are developed. Completing Medicare Wellness Visits meeting a set weekly quota, documenting all required components, addressing necessary health maintenance gaps in care, and developing individualized patient specific care plans. Appropriately documenting all nursing interventions in the electronic medical record. Reviewing the chart for completeness, test results, and billing. Utilizing Excel to maintain an accurate list of patients eligible for Medicare Wellness Visits, patients with completed visits, and documenting outreach to patients. Following transition of care management/hospital follow up workflow completing 48-hour transition of care outreach to patients coordinating care to ensure all discharge needs are met, and arranging hospital follow up appointments for patients. Providing chronic care management services to patients collaborating directly with SACO/SQCN care management team members to improve patient medication adherence, fulfill DME requests, assist with obtaining referrals, and coordinating care with specialists' office. Identifying patients who would benefit from additional care management support and placing referrals/orders for necessary services. Completing all Epic in basket requests appropriately. Administering injection of medications or immunizations in accordance with approved nursing protocols. Observing patient for any reaction to medications or immunizations, treatments, and significant incidents. Attending Care Management Meetings, Primary Care Collaborative meetings, and other educational sessions as scheduled. Will complete recommended educational modules as assigned. Assisting in clinic with rooming and triaging patients as needed. Providing basic patient care as ordered. Responding to life threatening situations based upon nursing standards, policies, procedures, and protocols.

Qualifications include the ability to manage time effectively and work independently to complete all assigned tasks. Ability to work with other team members as part of the interprofessional collaboration team. Ability to make professional nursing decision up to the scope of practice for licensure and possess the knowledge and critical thinking skills to support those decisions. Customer service skills and ability to communicate effectively with patients and other team members. Ability to navigate EHR system and complete any necessary documentation. Knowledge and critical thinking skills to safely provide triage to patients collecting all pertinent information for decision making. Ability to effectively communicate SBAR information to providers and execute any additional orders. Ability to multi-task and manage multiple competing priorities. Active Virginia LPN License (required). Active AHA BLS CPR certification.

Preferred knowledge of general quality measures for outpatient clinics. Knowledge about ACOs and QCN and their impact on patient care. Entry level experience with Excel with the ability to update, filter, and track information.

Location: US-VA-Portsmouth

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