Chronic Care Management Coordinator

JOB SUMMARY:

The Chronic Care Management Coordinator (CCM Coordinator) Provides care management for adult and pediatric patients with complex illnesses, in the primary care setting, under the Supervision of the Chronic Disease Project Manager. In partnership with the primary care practice leadership team, the CCM Coordinator leads care management within the team through process improvement, workflow redesign, helping with training, and delegating to other members of the team. Serves in an expanded health care role to collaborate with specialists, members of health care team, and patients/families to ensure delivery of quality, efficient, and cost-effective health care services. Assesses plans, implements, coordinates, monitors, and evaluates all options and services with the goal of optimizing the patient's health status. Integrates evidence-based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care. Provides other duties as assigned by Chronic Disease Project Manager.

Provides targeted interventions to avoid hospitalization and emergency room visits. Coordinates care across settings and helps patient/families understand health care options.

JOB DUTIES AND RESPONSIBILITIES:

1. Identifies the targeted CCM population within practice site(s) per primary care provider (PCP) referral, risk stratification, and patient lists. Includes patients with repeated social and/or health crises.

2. Assesses over time the health care, educational, and psychosocial needs of the patient/family. Uses standardized assessment tools such as depression screening, functionality, and health risk assessment.

3. Collaborates with PCP, patient, and members of the health care team, including continuum of care settings and community. Responsible for developing a comprehensive individualized plan of care and targeted interventions. Continually monitors patient/family response to plan of care and revises the care plan as indicated.

4. Provides patient self- management