Chronic Care Management Nurse

Supervised by: Chief Quality Officer

Position Overview:

The Chronic Care Management Nurse plays a pivotal role in providing personalized care for patients with chronic conditions, including but not limited to diabetes, hypertension, asthma, COPD, heart disease, and other long-term illnesses. This role involves monitoring patients' health status, educating them on their conditions, ensuring adherence to treatment plans, and promoting proactive measures to prevent complications. The Chronic Care Management Nurse collaborates closely with physicians, care teams, and patients to deliver high-quality care in a clinic setting.

Working Environment:

• Clinic Hours: Monday to Friday, 8:00 AM – 5:00 PM (with occasional extended hours depending on patient needs).

• Environment: Fast-paced, team-oriented, and patient-focused clinic setting.

• Physical Demands: Standing, walking, and sitting for extended periods. Occasional lifting of patients or equipment may be required.

Key Responsibilities:

Patient Care & Management:

• Chronic Disease Management:

  • 
    Monitor and assess the health status of patients with chronic conditions, including vital signs, lab results, medications, and treatment adherence.
  • Provide ongoing education and support to patients on managing their chronic conditions and improving health outcomes.
  • Collaborate with physicians and other healthcare providers to develop and implement personalized care plans based on patient needs.
  • Offer routine assessments for patients in both in-person and remote settings, such as phone calls or telehealth visits.
• Medication Management:
  • 
    Educate patients on the proper use of prescribed medications and monitor for adherence, side effects, and potential drug interactions.
  • Coordinate medication refills and communicate with pharmacies/providers as necessary.
  • Assist in adjusting medication regimens as ordered by the physician, in accordance with established protocols.
• Care Coordination:
  • 
    Act as a point of contact for patients with chronic conditions, ensuring that all aspects of care are coordinated, including referrals, tests, and specialist visits.
  • Communicate and follow up with patients to ensure continuity of care and address any issues or concerns promptly.

  • Monitor patients' progress and identify early signs of complications or deterioration in their condition.

Education & Support:

• Patient Education:

  • 
    Provide education on managing chronic diseases, including self-management skills, lifestyle changes, diet, exercise, and coping strategies.
  • Educate patients and their families on the importance of preventative care, such as routine screenings, immunizations, and other health-related behaviors.
  • Use self management methods to ensure patients understand their treatment plans and health goals.
• Health Promotion:
  • 
    Help patients set realistic, measurable goals to improve their health and quality of life.
  • Guide patients through disease-specific management strategies, including symptom monitoring, tracking triggers, and recognizing warning signs.

  • Empower patients to take ownership of their health and become active participants in their care plans.

Documentation & Reporting:

• Patient Records:

  • 
    Maintain accurate and up-to-date patient records in compliance with clinic policies and relevant regulations (e.g., HIPAA).
  • Document patient assessments, care plans, interventions, progress notes, and any changes in condition or treatment in the electronic health record (EHR).

  • Complete required reports related to chronic care management programs, including billing and outcome documentation.

Quality Improvement:

• Outcomes Monitoring:

  • 
    Track and report on the effectiveness of chronic care management services, identifying areas for improvement in care delivery.
  • Participate in quality improvement initiatives aimed at improving patient outcomes and enhancing the overall care process.

  • Support the clinic’s efforts to meet accreditation standards, quality measures, and performance benchmarks for chronic care management.

Skills and Qualifications:

• Education and Certification:

  • 
    Registered Nurse (RN) or Licensed Practical Nurse (LPN)with an active state license.
  • BLS (Basic Life Support) certification
• Experience:
  • 
    Minimum of 2-3 years of nursing experience, with a focus on chronic disease management, geriatrics, or related areas.
  • Experience working in a clinic or outpatient setting preferred.
  • Knowledge and experience in patient education, health promotion, and care coordination.
• Technical Skills:
  • 
    Proficiency with Electronic Health Records (EHR) systems.
  • Basic knowledge of chronic care management programs and healthcare regulations.
  • Familiarity with telemedicine platforms and remote patient monitoring is a plus.
• Interpersonal Skills:
  • 
    Excellent communication skills, both verbal and written, to effectively interact with patients, families, and healthcare professionals.
  • Ability to work collaboratively within a multidisciplinary team.
  • Strong critical thinking and problem-solving skills, with the ability to assess complex situations and make sound clinical decisions.
• Personal Attributes:
  • 
    Empathy and compassion for patients with chronic conditions.
  • Strong organizational skills and attention to detail.
  • Ability to manage a high volume of patients and prioritize care effectively.

Additional Information:

The Chronic Care Management Nurse is a critical member of our care team, dedicated to improving the health and quality of life of patients with chronic conditions. This role provides an opportunity to make a meaningful difference in the lives of patients, empowering them to manage their health and prevent complications associated with chronic diseases.