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Southern Indiana Community Healthcare

Title/position: Chronic Care Nurse

Current LPN or RN license for the state of Indiana.

Supervisor: Enabling Services Director/Office Manager

Described Duties:

The chronic care nurse performs care management for Medicare patients who are chronically ill with at least two chronic diseases such as chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, and/or congestive heart failure. The chronic care nurse works in collaboration and continuous partnership with chronically ill patients and their family or caregivers, clinic providers and community resources in a team approach to increase patient's ability for self-management and shared decision making.

Primary Responsibilities:

1. Can fulfill the clinic's mission to spread the love of Christ through quality health care to those in need while providing appropriate physical emotional and spiritual care for the whole person.

2. CCN will build and maintain a professional relationship with providers staff and patients while educating and promoting the CMS approved and guided CCM program and carry out the goals and objectives of SICHC in according to established policies & procedures.

3. Responsible for registry of chronic care management (CCM) patients.

4. Validates enrollment of CCM patients based on providers’ request.

5. Conducts minimum of 20-minute telephone call or non-face to face counseling or education per month to each CCM patient on their roster.

6. Complies with documentation requirements of the chronic care management program by carrying out the care plan with the patient, family or caregivers and providers and documenting in the EMR.

7. Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, and facilitate changes as needed.

8. Creates an ongoing process for patient and family/caregivers to determine and request the level of care coordination support they desire.

9. Facilitates patient access to appropriate medical and specialty providers.

10. Oversees the transition of inpatient to outpatient care in an effort to decrease readmission rate and partners with the transition to care management team.

11. Work closely with office providers to manage the day-to-day calls involving symptom control, medication management, and provide patient and family education.

12. Educates patients and family or caregivers about relevant community resources.

13. Assist with the identification of high-risk patients (the chronically ill and those with special health care needs) and assist on the enrollment of these to the patient registry.

14. Coordinates continuity of patient care with external healthcare organizations and facilities including from the primary care provider to a specialty care provider.

15. Supports patient self-management of disease and behavior modification interventions.

16. Provides patient health counseling, education, and instructions.

17. Track and report patient numbers, timely completion of paperwork by the end of the month as assigned by your supervisor or manager and utilize excel tracking sheet to document daily, weekly, and monthly work assignments.

18. Assist in developing new programs using the chronic care model.

19. Assist Enabling Services Director and CHW with duties as needed.

20. Participates in webinars conferences and other SICHC approved trainings to improve knowledge and skills related to job needs and attend meetings as required to accomplish program goals.

21. Participate in the in services and other training programs that are job related.

22. Plan and assist with public relations activities as needed including health fairs and other public events.

23. Represent SICHC effectively to external agencies.

24. Perform related work as required, in accordance with license, certification and training when providing direct patient care.

Essential Job Functions:

1. Maintain a high level of ethical conduct regarding confidentiality and professionalism.

2. Employees required to effectively communicate using SICHC's core values.

3. Job duties require employee to provide excellent customer service to all internal and external patients.

4. Employee will be required to use different methods of communication. (LEP; Propio)

5. Effectively provide written communication and electronic communication

6. Be able to give verbal health presentations in different locations settings and group size.

7. Possesses cognitive skills necessary to understand terminology medical records & instruction.

8. Ability to demonstrate competent use of the EMR and follow up of CCM reason responsibilities.

9. Timely completion of paperwork by the end of the month as assigned by supervisor or manager and utilizes excel tracking sheet to document daily weekly monthly work assignments.

10. Requires basic organizational skills typically to organize own work job duties require the ability to work independently and as a part of a team.

11. Ability to prepare basic correspondence and simple reports in Microsoft Word

12. Ability to use Microsoft Excel and publisher to create tab tables and simple displays of information.

13. Ability to create send and manage e-mail in Office 365

14. Ability to access web-based applications and programs or others as assigned by supervisor (example the hypertension program) and will regularly communicate information to the patient provider.

15. Employee can effectively select from alternatives to situations encountered on the job.