This position will be responsible for contacting, through telephone calls, patients that have been enrolled into the Chronic Care Management program at ARH. During these calls the Medical Assistant will review care plans and properly document further education provided to the patient. The Chronic Care Management program is designed to promote and encourage healthy life styles to patients that have multiple chronic diseases.
Communication and Collaboration
1. Completes Comprehensive Health Assessment on each new patient and once per year.
2. Incorporates and facilitates resources and supports as needed.
3. Serves as a resource and maintains positive and effective relations with nursing, medical staff, and other organizations/customers.
4. Works with a team consisting of patients, physicians, nurses, home health, remote monitoring, and other health care providers to direct, document, assess, and measure the care being provided.
5. Manages care transitions among providers and settings, including referrals to other clinicians, follow-up after emergency department visit, follow up after hospital and other health care facilities discharge.
1. Reports potential patient problems identified during review to CCM Registered Nurse.
Patient & Family Education
1. Reinforces engagement of patients and their families in their own care and supports self-management. Elements include the patient’s clinical condition, feasibility of completing various interventions, and the patient’s values, preferences and readiness to engage in self-management and treatment.
2. Reinforces education and instruction of the disease process, diet, activity, medications and medication reconciliation. Coordinates care, such as physician visits, therapies, self-care and long term management, if needed.
Planning & Managing Care
1. Plans, facilitates, and initiates contact with the newly established patient referrals and coordinates the continuum of patient care.
2. Provides at minimum, 20 minutes of non-face-to-face care coordination per month.
3. Completes a monthly health assessment.
4. Reviews medications for adherence.
5. Acts as the communicator/advocate between patient and provider to promote adherence.
• LPN Strongly Preferred
• Ability to maintain confidentiality with all aspects of information in accordance with the practice, State and Federal regulations.
3+ Years preferred
Computer knowledge (Microsoft Word, Microsoft Excel, Practice Plus), Great Communication Skills, Positive Attitude, Self-Motivated, Organizational skills, Medical terminology, Problem solving, Patient Advocate, Capable of multi-tasking, good typing skills, must be a team player, Ability to maintain confidentiality with all aspects of information in accordance with the practice, State and Federal regulations