Chronic Care Management

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

Benefits offered by this job

401k with profit sharing

Health insurance (medical)

Dental and vision

Life and disability

Job summary

PRIMARY CARE PARTNERS in Grand Junction, Colorado, is seeking a compassionate Medical Assistant to become our Chronic Care Manager. You will coordinate care for patients with chronic diseases and provide health coaching.

The role requires EMR experience, excellent time management and strong communication. You’ll work full-time, Monday–Friday, 8:00 a.m. to 5:00 p.m., and participate in ongoing training and quality improvement.

Qualifications

• Medical Assistant with EMR experience required.
• Excellent time management and communication skills.
• Ability to maintain patient privacy and confidentiality.

Responsibilities

• Perform CCM calls and coordinate care for chronic disease patients.
• Educate patients on conditions, treatments, and medication management.
• Manage appointment scheduling with primary care and specialists.
• Provide non-face-to-face contact and health coaching to promote self-management.
• Collaborate with care team to mobilize community resources.
• Bill CCM services per CMS guidelines and monitor care plans.

Skills

Medical Assistant

EMR experience

Active listening

Privacy and confidentiality

Education

Certified Medical Assistant

Tools

EMR software

Job description

Join Our Team as a Chronic Care Manager – Medical AssistantAre you a compassionate and detail-oriented Medical Assistant looking to take the next step in your career? We’re seeking a dedicated Chronic Care Manager to join our healthcare team and make a meaningful impact in patient care coordination. This role offers a dynamic work environment, professional growth opportunities, and an exceptional benefits package that includes: Why Join Primary Care Partners? We Take Care of You While You Care for Others! At Primary Care Partners, we believe that taking care of our team is just as important as taking care of our patients. That’s why we offer:Base pay $22.84-25.84Benefits $7-8Combined 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)The telephone Chronic Care Management Nurse (CCM) will promote effective partnerships among patients, families, nurses, physicians, other qualified healthcare providers and clinical disciplines to coordinate care for patients with chronic disease and facilitate a shared goal model. The CCM nurse will provide effective clinical health coaching to assist patients with self-management of their chronic disease and life-style changes to mitigate health risks.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 contactProvide 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.Maintain a relationship and knowledge of community services and partners available and/or involved with patients’ care.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.Bill for CCM per CMS guidelines.Hospital DischargesUtilize family division daily discharge reportConduct Transition of Care (TOC) patient assessment within 2 days of dischargeReview discharge instructions, medication reconciliationFacilitate scheduling of follow up visit for family divisions within 7 days including day of dischargeFacilitate patient access to appropriate primary care as well as care coordination team to support unmet social needs, transitions, referral to care managementMiscellaneous: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 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 AssistantExperience working in an EMR, which is required.Demonstrate active listening skills and communicate effectively both written and verbally.Excellent time management skillsExcellent communication skillsWell-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.QualificationA 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 skillsWell-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.