Job DescriptionDescription of Primary Responsibilities
Supports comprehensive care management of Medicare patients in support of FHCN health-care team by providing twenty minutes of patient education and care coordination monthly to Medicare patients who have two or more chronic diseases. - Outreach to eligible FHCN patients to educate and enroll them in the Medicare Chronic Care Management (CCM) program.
- Coordinates the creation of a person-centered, electronic care plan (Comprehensive Care Plan) based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues, with particular focus on the chronic conditions being managed).
- Maintains Comprehensive Care Plans by reviewing and updating (if necessary) annually.
- Ensure continuity of care with a designated member of the care team with whom the patient is able to schedule successive routine appointments.
- System-based approaches to ensure timely receipt of all recommended preventive care services.
- Medication reconciliation with review of adherence and potential interactions.
- Oversight of patient self-management of medications.
Provide health promotion services similar to the role of a health educator, such as providing training materials and teaching self-management skills pertaining to the patient's goals identified in the Comprehensive Care Plan. - Encouraging and supporting health education for the patient and family/support persons.
- Assessing the patient's and family/support persons' understanding of the patient's health condition and motivation to engage in self-management.
- Coaching patient's and family/support persons about chronic conditions and ways to manage health conditions based on the member's preferences.
- Linking the patient to resources for: smoking cessation, management of chronic conditions, self-help recovery resources, and other services based on patient needs and preferences.
- Using evidence-based practices, such as motivational interviewing, to engage and help the patient participate in and manage their care.
- Utilizing trauma-informed care practices.
CCM Specialist interfaces with patients and other stakeholders through a variety of mechanisms, including, but not limited to: - Individual, face-to-face contacts through both appointment and warm hand-off contacts;
- Telephone and other electronically mediated contacts; and
- Contact outside of FHCN Health Centers to provide linkages to appropriate community resources based upon the patients' identified needs and goals through the Health Action Plan. This could be a mobile unit for example.
During contacts with health-care team members at FHCN and from other organizations, CCM Specialists reduce barriers to care in a number of ways including but not limited to: - Preparing, printing and distributing the information necessary for care teams to engage in Pre-visit Huddles.
- Maintaining regular communication with care team providers on patient care plan goals and progress.
- Facilitating regular communication between patient and other health-care team members both inside and outside FHCN.
- Providing staff training and education sessions necessary to implement health education and care coordination services.
- Participates in meetings and trainings as necessary to facilitate the above duties, including those geared toward implementing evaluation tools that determine the effectiveness of CCM Specialist functions.
Performs other duties as assigned.Description of Primary AttributesProfessional & Technical Knowledge:
Possesses work-related skills at a higher level than completion of high school, including formal written and verbal communications skills, computational and computer skills, mathematical, technical or health care related knowledge frequently acquired through completion of a trade school, para-professional, or certificate type program. Requires at least three years of health care related work experience. Bachelor's Degree in related field preferred. Technical Skills:
Ability to prepare more complex documents in Microsoft Word, including creating tables, charts, graphs and other elements. Ability to use Microsoft Excel to review and compile data, including the use of formulas, functions, lookup tables and other standard spreadsheet elements. Ability to create basic presentations in Microsoft PowerPoint.Licenses & Certifications: None requiredCommunications Skills:
Job duties require the compilation of information prepared in effective written form, including correspondence, reports, articles or other documentation. Effectively conveys technical information to non-technical audiences.Physical Demands: The physical demands described here in this job description are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this position, the employee is regularly required to sit and use repetitive hand movement to type and grasp. The employee is frequently required to stand or walk; and occasionally lift and/or move up to 20 pounds. Pay Scale:Min Hourly Rate: $21.25Max Hourly Rate: $29.33