Chronic Care Management

PRIMARY CARE PARTNERS INC; Grand Junction (CO); On-site; USD 31,000 - 36,000; Full time

Benefits offered by this job

Health insurance

401k with profit sharing

Dental and vision benefits

Life and disability insurance

Job summary

Primary Care Partners Inc in Grand Junction, CO is seeking a Chronic Care Manager – Medical Assistant. This full-time role focuses on telephonic management of patients with multiple chronic conditions, coordinating with PCPs and care teams to improve outcomes outside the clinic.

The position runs 40 hours per week, typically 8:00 a.m.–5:00 p.m., with stable day shifts. The ideal candidate has at least two years’ nursing or caregiver experience, EMR proficiency, strong active listening and

Qualifications

• Medical Assistant certification or two years’ experience in social work/case management in healthcare or medical setting.
• Experience in a primary care environment with population health exposure is desirable.
• Proficiency with electronic medical records (EMR) is required.

Responsibilities

• Perform Chronic Care Management (CCM) calls and communications with patients identified by PCPs.
• Educate patients on conditions, medications, and treatment plans.
• Coordinate with care team to maximize non-face-to-face contact.
• Facilitate access to community resources and social services for patients.
• Bill for CCM per CMS guidelines and ensure documentation accuracy.

Skills

Active listening

Time management

Privacy compliance

Education

Medical Assistant Certification

Case management experience in healthcare

Tools

EMR system

Job description

Job Details

Job Location: Management Services - GRAND JUNCTION, CO 81506, Salary Range: $22.84 - $25.84 Hourly, Job Shift: Day, Join Our Team as a Chronic Care Manager – Medical Assistant

Why Join Primary Care Partners?

We Take Care of You While You Care for Others!

At Primary Care Partners

Base pay $22.84-25.84
Benefits $7-8
Combined with base pay our Robust Benefit coverage includes outstanding retirement including annual 401k contribution and profit sharing, 100% coverage for Health insurance, life, disability and multiple other benefits incl. Dental, vision, critical illness and injury coverage, long term care, pet insurance etc.

Chronic Care Management (CCM)

Role: The CCM works with Primary Care Providers (PCP), care team staff, and 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. CCM provides information about resources available to help them. CCM specialists also make referrals for social services like housing options, financial assistance, support groups etc. 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.

Essential Functions & Responsibilities

• Perform Chronic Care Management (CCM) calls and communications with patients identified and designated by the providers under the direction of the Practice Transformation Director.
• Make outgoing calls to CCM patients to assist patients in managing their chronic diseases - including education about their conditions and treatment regimens, medication management, appointment management with primary care and specialist providers.
• Responds to incoming telephone calls from CCM patients. Instructs patients and families regarding medication and treatment instructions.
• Maximize use of qualified clinical staff within the care management team to provide non-face-to-face patient contact
• Provide education and clinical health coaching interventions to motivate patients and families toward successful self-management of chronic disease.
• Effectively partner with the patient and provider practice team members to mobilize needed community resources for the patient and family.
• Implement, contribute to, and modify a patient care plan based on mutual goals with the patient, family, the providers, medical summary, and ongoing action plan, as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion and facilitate changes as needed.
• Facilitate patient access to appropriate medical and specialty providers as indicated by physician or qualified healthcare provider.
• Coordinate social support services for patients; mobilizing resources that might be of assistance, making resources referrals.
• Bill for CCM per CMS guidelines.

Miscellaneous

• Participate in office meetings related to performance improvement, quarterly and annual quality reports, electronic health record enhancements, and budgeting activities.
• Attend and actively participate in all Chronic Care Management, Care Coordination related training and meeting activities, i.e., Health Coach, workshops, scheduled webinars, cohort calls and one-on-one meetings, as needed.
• Ensure all required elements are documented for CCM billing.
• Ensure a high standard of nursing care to patients, while working within company policies, procedures, and standard of care.

Qualification

• Medical Assistant, or a minimum of two years’ experience in social work/case management in a healthcare or medical setting.
• Significant experience within a primary care setting with quality/population health experience in lieu of certification will be considered.
• Experience working in an EMR, which is required.
• Demonstrate active listening skills and communicate effectively both written and verbally.
• Excellent time management skills
• Well-versed in privacy policies and maintain the confidentiality of personal health information for all patients.
• Adhere to the highest standards of personal and professional conduct.

Position Type/Expected Hours of Work

This is a full-time position at 40 hours a week. Works primarily Monday through Friday between 8:00 a.m.–5:00 p.m. Expected hours of work may change at any time with or without notice.

Working Conditions

Works in a well-lighted, ventilated area; standing, sitting, walking with a varying frequency of moderate lifting. Noise level: Moderate: The work involves some background noise but is not constant loud communication.

Risk Level

Moderate Exposure

Qualifications

• A minimum of two years providing nursing care to chronically ill patients, especially in home health or primary care settings.
• Experience working in an EMR, which is required.
• Demonstrate active listening skills and communicate effectively both written and verbally.
• Excellent time management skills
• Well-versed in privacy policies and maintain the confidentiality of personal health information for all patients.
• Adhere to the highest standards of personal and professional conduct.