Ambulatory Chronic Care Manager

Cameron Health is an independent, not-for-profit facility that proudly serves Angola and Steuben County. We’ve been a cornerstone of this community and the surrounding area in northeast Indiana dating back to 1926. Over the years, we’ve helped generation after generation of area residents enjoy better health and live comfortably. Today, Cameron Hospital has grown into something more than a simple community hospital. Filled with advanced equipment and skilled specialists, Cameron is a modern, high-tech facility that provides advanced diagnostics, a variety of specialties and cutting-edge treatment options that are combined with highly personalized and compassionate care. Low nurse to patient ratios allows time for exceptional quality care and patient focus. Our care teams consist of RN's, Charge Nurses, Patient Care Techs, Unit Secretaries and a night shift hospitalist NP. DEPARTMENT: Population Health JOB TITLE: Ambulatory Chronic Care Coordinator SHIFT: Days Summary/Objective The Population Health Nurse will focus on improving the health status and care for individuals with chronic health conditions; potentially complex medical, behavioral health, and psychosocial/social determinants of health; and transitional care management processes for individuals. Essential Functions Demonstrates service excellence at all times. Exhibits excellent guest relations to patients, visitors, and team members. Identifies and engages patients that qualify for chronic care management and transitional care management. Collaborates electronically and in-person with a diverse patient/family population to create individualized LPOCs including, but not limited to: Assessing the patient and family’s unmet health and social needs, Providing effective communication to improve health literacy, Continuously developing a LPOC based on mutual goals with patient, family, and provider’s emergency plan, medical summary, and ongoing action plan, as appropriate Assists with navigating the patient through the healthcare system and available resources, Monitoring patient’s adherence to LPOC and progress towards goals in a timely fashion Facilitating needed changes for patient, family, and LPOC, and Creating ongoing processes for patients/families to determine and request the level of care coordination support they desire over time. Facilitates patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g. Dietician, Pharmacy support, etc.) Cultivates and supports primary care and subspecialty co-management with timely communication, inquiry, follow up, and integration of information into the care plan regarding transitions-in-care and referrals. Completes documentation of patient care, patient condition, reactions, response to treatment, and patient progress in a timely manner that meets care management expectations. Adds appropriate charges to documentation. Maintains focus on patient centered care and customer service. Serves as a point of contact, advocate, and informational resource for patient, family, care team, payers, and community resources. Works with population health team members and other disciplines in the provision of care to offer comprehensive wellness strategies. Facilitates/attends meetings as needed between patient, families, care team and community resources. Identifies needs for transitional care, medication reconciliation, and takes steps to assure the transition is effective for patients and family members. Demonstrates interpersonal and observational skills needed to effectively identify appropriate psychosocial adaption to illness and/or the presence of psychopathology (e.g., depression, anger, etc.). Understands and utilizes contemporary theories of health behavior change in helping patients and/or family members reach established goals. Collects and aggregates data on LPOCs that assists in program evaluation and identifying improvement opportunities. Participates in ongoing education and professional development for department and self. Participates in continuous quality improvement activities (CQI). Participates in staff meetings and other meetings as required. Qualifications Experience Care management and patient navigation experience preferred. Experience in a physician healthcare office preferred. Knowledge of local and regional community resources preferred, Skills/Competencies Excellent communication skills required. Ability to multitask, organize, and complete assignments in a timely manner. Must be able to efficiently manage time with minimal supervision. Competent in Epic EMR system preferred. Education Required Graduate from an accredited nursing program required. Bachelor's degree highly preferred. Certifications Required or Preferred Advanced care planning certification preferred. Physical Demands The physical demands of this job are such that requirements fall under a Level 3 category which is considered Medium Duty. Please refer to the full physical demand sheet for further information. Requirements