Job Description

Position Summary:

The CCM Specialist works with Primary Care Providers (PCP), care center staff, and Nurse Care Managers to provide telephonic management of patients with multiple chronic conditions and increased risk factors to ensure excellent care is provided outside of office visits. Responsible for facilitating quality care in accordance with established clinical practice guidelines and protocol and PCP direction. Fosters patient engagement and adherence to plan of care to achieve evidence based clinical objectives and goals specific to chronic conditions and preventive health measures.

Job Responsibilities:

• Manage patient care telephonically, through the following methods:
• Review of the patient’s medical, functional, and psychosocial needs
• Medication reconciliation with review for adherence
• Encourage and facilitate timely receipt of all recommended preventive services
• Reinforce disease self-management education and preventive care guidelines,
• communicate PCP instruction and advice, and provide patient education materials
• Referral to and coordination with community service organizations and make and/or specialist appointments and schedule other tests, treatments or procedures as needed
• Notify patients of lab results, any changes in provider orders, specialist appointments, etc. and document notification in the EMR.
• Managing care transitions between healthcare providers and settings, including assistance with referrals to outside providers, follow up after hospital or emergency room visits, or stays in skilled nursing facilities
• Facilitating patient follow-up visits with PCP for acute or chronic needs
• Documents all concerns and follow-up and escalates to the Nurse Care Manager, Clinical Team, or PCP when appropriate
• Communicate with and assist patients in a professional and courteous manner.
• Work as part of the healthcare team to assess patient needs, plan and modify care and implement interventions.
• Communicate with the healthcare team to provide a proactive approach to patient care.
• Obtain lab, x-ray and other reports and results, hospital notes, referral information, consults, etc.
• Monitor, track and resolve outstanding orders, referrals, consults, labs, procedures, etc. in EMR.
• Answer patient calls and determine how to assist them as needed. Triage patient needs and identify necessary plan of action within office policy such as scheduling an appointment, triaging for a provider or directing the patient to the ER, etc. as needed.
• Adhere to infection control safety guidelines and confidentiality policies.
• Complete training for Centra's Provider Portal and utilize the Portal to obtain test reports and results, consult notes and other records as needed.
• Fulfill organizational responsibilities as assigned which include: respect and promote patient's rights, respond quickly and appropriately to emergency situations and share problems relating to patients and/or team members with Practice Manager or supervisor quickly.
• Provide safe, patient centered, compassionate and competent care.
• Establish and maintain effective working relationships with patients, providers, team members, insurance companies and the public. Work with peers and providers in a team environment.
• Participate in quality improvement projects. Attend training and meetings as required.
• Maintain annual competencies for medical assistant certification or registration or nursing license.

Qualifications

• Maintain CPR certification.
• Knowledge of medical terminology.
• High school diploma or equivalent required
• Associate’s Degree or higher preferred
• Medical office experience preferred
• Certified Medical Assistant Certification

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