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LPN / RN - Case Manager

Gaston Family Health Services | 200 East Second Ave, NC | Full Time

Job Description

Position Description:

 The Nurse/Chronic Care Manager (CCM) will contact patients, make appointments, perform patient assessments, development care plans and provide a range of duties to support practice meeting specific quality requirements for reimbursement and shared savings. The CCM works within the clinic/practice setting or remotely to help manage the practice’s patients, communicating and documenting services and interventions.

The Chronic Care Manager works primarily with the adult and disabled populations, serves as a lead to ensure that the care management patients are fully engaged in and understand chronic conditions, goals and that program processes are developed and implemented to achieve targeted outcomes. In addition to having a strong clinical background, the Chronic Care Program Manager understands the service delivery systems for the aged, blind and disabled populations, the interplay between the Medicare and Medicaid programs, long term care services and supports (LTSS), care management information systems, and quality improvement measures and processes.

The Chronic Care Program Manager attends information sessions, participates in chronic care meetings and helps plan for implementation of chronic care and clinical initiatives. The Chronic Care Manager works collaboratively with team members to improve patient care, better utilize services and reduce medical cost.

The Chronic Care Manager ensures optimum productivity and coordination with other Network functions including: Pharmacy, Behavioral Health, OB and Pediatrics, Quality Improvement, Practice Relations, and information technology supports

Minimum Education: LPN or RN from an accredited program with a license to work in North Carolina.

Experience: Minimum 2 years of care management experience and 5 years patient nursing experience with adults.

Additional skills required: Demonstrated clinical competence in disease management and care management principles; knowledgeable in population health management. Self-motivated and able to work as part of a team. Ability to follow a variety of operational details and program requirements. Ability to develop and present reports and implement processes with multiple team members. Strong communication skills and demonstrates good judgement. Familiar with practice operations and work flows. Basic understanding of ACO’s and Value-Base care, Medicaid and Medicare. Strong organizational, analytical and time management skills. Competence in establishing rapport with patients and providers. Knowledge of and compliance with federal and state regulations applicable to the position.

Key Responsibilities: 

  1.  Proficiently and systematically uses data from EHR to target patients and providers for outreach, education, and intervention and records and reviews data within the practice’s EHR.
  2. Proficiently and systematically performs and records outcome of patient assessments.
  3. Effectively interacts and communicates with the patient, provider, and other members of the care team. Utilizes the Wellness team in planning care for patients. Communicates and coordinates with all providers and members of the care team, in an effort to minimize fragmented care.
  4. Assists and advocates for patients to access care, services, and treatments in the most cost-effective healthcare setting with emphasis on linkage to their medical home.
  5. Addresses the total patient and support systems (i.e. caregiver, family, etc.), inclusive of medical, psychosocial, behavioral, cultural and spiritual needs.
  6. Involves the patient and their support systems in the decision-making process. Utilizes motivational interviewing techniques to measure a patient’s understanding and acceptance of the proposed plans, his/her willingness to change, and his/her support to maintain health behavior change. Provides coaching, information and support to empower the patient to make ongoing independent and/or healthy lifestyle choices.
  7. Documents clearly, completely and concisely in EHR related to all case management activities.
  8. Monitors quality and effectiveness of interventions for the patient by setting both long term and short term specific, measurable goals. Facilitates Quality Improvement activities that educate, support, and monitors providers regarding evidence based care for best practice/National Standards of Care.
  9. Advocates for patients and supports providing delivery of appropriate, evidence based care by all care providers.
  10. Willingly performs other duties as assigned within scope of practice.


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