Chronic Condition Manager - Lexington, SC

MH Health Care Services PC; Lexington (VA); Hybrid; USD 75,000 - 95,000; Full time

Benefits offered by this job

Health benefits

Family benefits

Paid time off

401(k)

Job summary

Marathon Health is a leading primary care provider that partners with employer and union plans across the United States. The Chronic Condition Manager will educate, coach, and manage chronic disease programs for patients at various locations, in-person or virtually, while coordinating with client vendors to ensure cohesive care.

The role requires RN licensure with at least 3 years in chronic disease management; CDCES certification is strongly preferred.

Qualifications

• RN required with at least 3 years in chronic disease management.
• CDCES certification strongly preferred.

Responsibilities

• Facilitate, develop, monitor, and report on chronic condition programs.
• Educate, counsel, and coach patients in person, virtually or telephonically.
• Coordinate efforts with client vendors to ensure cohesive services.
• Document in EMR and use data to inform enrollment and care.
• Engage patients via outreach by phone, email, and mail.

Skills

Chronic disease management

Patient education & coaching

Clinical documentation

Telehealth / virtual coaching

Education

RN license or eligibility

Job description

Marathon Health is a leading advanced primary care provider, partnering with employer and union plan sponsors to improve health for millions of Americans. With nationwide onsite, nearsite, and network health centers, and virtual primary care, Marathon delivers a value-based model that enhances the healthcare experience for members and providers, while driving meaningful cost savings for plan sponsors. Marathon is proud to be certified as a Great Place to Work®, reflecting the company's commitment to building an inclusive, high-trust culture where all employees can thrive. Learn more at marathon.health

ABOUT THE JOB

Facilitate, develop, monitor, measure, and report on wellness and chronic disease prevention and management programs that complement the Health Center maintained and coordinated by Marathon Health. The Chronic Condition Manager will educate, counsel, and coach patients on how to prevent and/or manage chronic disease in face-to-face, virtual and/or telephonic formats, as well as in one-on-one and/or group settings. The CCM may also be responsible for developing educational materials. The CCM may be asked to coordinate efforts among all client vendors to provide cohesiveness of services and to better engage the client population. These duties are carried out for a specific client at its various locations.

ESSENTIAL DUTIES & RESPONSIBILITIES

• Facilitates chronic condition management and prevention programs, including but not limited to: Diabetes Management, Diabetes Prevention, Hypertension Management, Hyperlipidemia Management, COPD, Asthma, Obesity and Cardiovascular Disease.
• Programs include clinical, educational, and health coaching components
• Develops individualized interventions designed to improve and maximize health outcomes
• Conducts thorough and objective evaluations of the patients’ status, including psychosocial, physical, financial, and educational needs, prognosis, and past and present treatment course and services
• Identifies and enrolls individuals that qualify for chronic condition management programs
• Establishes supportive and confidential relationships with patients
• Assesses patients’ clinical and educational knowledge of chronic condition, readiness to change behavior and individualizes program/s based on needs
• Collaborates with other members of the healthcare team, such Nurse Practitioners, Physician Assistants, Medical Doctors, Health and Wellness Coaches, to optimize care and solve problems
• Conducts outreach via phone, email and regular mail
• Provides face-to-face, virtual and telephonic lifestyle and behavior-related health coaching in both individual and group settings
• Reviews HRA results, if applicable, and provides education and counseling to patients based on risk factors
• Follows workflow and policy guidelines for documentation in the electronic medical record, including the utilization of predictive modeling and behavior change analytics tools
• Applies critical thinking skills and problem-solving techniques to the condition management process
• Participates in the analysis of available data, review of reports, and strategy for enrollment of members to condition management programs
• Performs in-person, virtual, telephonic, and/or electronic proactive outreach to members that are eligible for disease management programs, as well as to unengaged members
• Utilizes Evidence Based Medicine in clinical decision making particularly with medication management, diagnostic and lab testing orders, and providing support/education to patients in making healthy lifestyle & behavioral changes
• Completes accurate, timely and thorough documentation in EMR system
• Support the mission, vision, and values of Marathon Health
• Participates in and complete all mandatory Marathon Health trainings and meetings and comply with organizational policies and procedures
• Participates in education sessions coordinated by Marathon clients for their respective, eligible patient population
• Coordinates efforts with other vendors (carriers, EAP, etc.) to inform client population of all available resources
• Communicates with Marathon Corporate and/or carrier to provide compliance-related information and necessary documentation
• Directs patients to onsite providers, primary care physicians, and/or specialists, as needed
• Maintains current knowledge of disease processes, available resources, and treatment options appropriate to patient populations
• Performs other duties as assigned

QUALIFICATIONS

• Registered Nurse (RN) required plus a minimum 3 years’ experience in chronic disease management. (Diabetes Care, Cardiac and Pulmonary Rehabilitation, etc.) Certified Diabetes Care and Education Specialist (CDCES), strongly preferred.

DESIRED ATTRIBUTES

• Passionate about transforming the way healthcare is delivered.
• Passionate about the patient experience.
• Desire to improve the quality of care for people.
• Enjoy working in a collaborative team environment where patients come first
• Entrepreneurial spirit and a passion for creating and driving best practices.
• Willingness to go the extra mile for patients.
• Great customer service skills.
• Ability to work autonomously.
• Demonstrated competence in multi-tasking
• Excellent critical thinking skills.
• Experience leading and developing presentations.
• High energy personal style and aptitude for process-oriented thinking
• Track record of consistent, stable employment along with the ability to work independently and as a part of a team

Pay Range: $75,000 - $95,000/yr The actual offer may vary dependent upon geographic location and the candidate’s years of experience and/or skill level. We are accepting applications for this position until a candidate has been selected.

BENEFITS

• Eligibility varies based on PT or FT status:
• Comprehensive Health & Wellness Benefits: Choice of 2 medical plans, 2 dental plans, and vision coverage, unlimited free mental health benefits and EAP resources, Rewards for challenges and healthy lifestyle activities
• Family Friendly & Reproductive Health Benefits: Family-building and hormonal health benefits and paid parental leave
• Time-Based Benefits: Generous PTO or FTO, Paid Holidays + A Day for What Matters
• Financial Support: Company paid Basic Life and Disability insurance, Supplemental Life, Spending Accounts, 401(k) with employer match and graded vesting
• Continuing Medical Education (CME) for maintaining and strengthening the knowledge, skills, and expertise of our health center teammates, as applicable

Marathon Health exists to enable millions of people to live their healthiest lives, one patient at a time. If you have a passion for improving patient lives while transforming a broken U.S. healthcare, Marathon is the place for you.

EEO & INCLUSION STATEMENTS

• Marathon Health provides equal employment opportunities to all teammates and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
• Marathon Health is committed to providing access and reasonable accommodation in its employment for individuals with disabilities. To request disability accommodation in the application process, contact [e-mail].
• Marathon Health will never ask a candidate for personal identifiable information (date of birth, social security number, driver’s license information, etc) via email or messenger tools, or for a financial deposit of any kind.
• All our open positions are listed here on our website and any emails sent from our teammates contain the address “@marathon.health” if you have any questions or concerns about suspicious emails or queries, please don’t hesitate to contact us directly at [e-mail].