Chronic Care Management Nurse JobWellington, FL 112605
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Chronic Care Management (CCM):Apply Now
Why You'll Love This Job
We are seeking a full-time Chronic Care Nurse to help enhance our delivery of quality patient care in our busy primary care practice in Wellington, Florida.
Chronic Care Management (CCM):
- Assisting with the identification, enrollment and management of qualified, high-risk patients.
- Development of patient-centered care plans
- Frequent telephonic reach-out to monitor and revise care plans
- Coordinate care with patient care team members to improve outcomes
- Assist with the identification of patients as they transition from ER, inpatient settings, and community rehabilitation centers.
- Ensure patients are seen within an appropriate time frame
- Maintain frequent telephonic communication in the post-transition period to prevent re-admission.
- Assist with the identification of high-risk patients that require remote vitals monitoring
- Analyze and track remote data and share with the patient care team
- Clinical Call Triage
- Assist with the triage of clinical patient calls from the phone center
- Assist with the interpretation and relaying of clinical results upon patient request
- Maintain a “Nurse Schedule” for timely evaluation of high-risk patients in coordination with the patient’s Primary care provider
- CCM enrollment and care plan development
- RPM set up
Skills & Qualifications
- Experienced Registered Medical Assistant, LPN, or RN (2 years minimum)
- Passionate about healthcare and patient experiences
- Knowledgeable of the most common chronic diseases, standard treatments, and associated pharmaceuticals
- Outstanding communication and telephone skills
- Electronic Medical Record experience preferred (EClinical Works)
- Works well with others and implements multi-disciplinary approach to improve patient outcomes
- Detail-oriented and able to multi-task
- 80% telephone-based tasks, 20% face-to-face patient care