SUMMARY: A Chronic Care Nurse (CCN) performs care management for chronically ill patients with at least two chronic diseases such as chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, obesity, hypertension, and/or congestive heart failure. The CCN works in collaboration and continuous partnership with chronically ill patients and their family/caregiver(s), clinic providers and community resources in a team approach to increase patients' ability for self-management and shared decision-making. The CCN works under the supervision of the Chronic Care Manager.
· Responsible for registry of chronic care management (CCM) patients.
· Validates enrollment of CCM patients based on provider request.
· Conducts minimum of one 20 minute of telephone or in-person counseling and education per month to each CCM patient on roster. Maximum monthly minutes is 60.
· Complies with documentation requirements of the Chronic Care Management program by carrying out the care plan with the patient, family/caregiver(s) and providers and recording in the EHR.
· Work with providers to establish care plans and goals for patients.
· Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, and facilitates changes as needed.
· Creates an ongoing process for patient and family/caregivers(s) to determine and request the level of care coordination support they desire.
· Facilitates patient access to appropriate medical and specialty providers.
· Coordinates transition of inpatient to outpatient care in an effort to decrease readmission rates.
· Work closely with in-office providers to manage chronic care conditions of patients between office visits.
· Educates patient and family/caregiver(s) about relevant community resources.
· Coordinates continuity of patient care with external healthcare organizations and facilities including from the primary care provider to a specialty care provider.
· Supports patient self-management of disease and behavior modification interventions.
· Provides patient health counseling, education and instruction.
· Graduate from accredited School of Nursing
· Current RN License in the State of Kentucky
· Minimum of ten years (10) work experience in a healthcare setting involving patients with complex chronic disease states preferred. Must have inpatient and outpatient work experience. Geriatric patient experience a plus.
· Strong working knowledge of chronic disease states including chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, and congestive heart failure and basic medical management of these states
· Must be highly motivated, result-oriented with strong skills in presenting, communicating, organizing, multi-tasking and time management skills
· Strong organizational and interpersonal skills
· Excellent customer service skills demonstrated by positive feedback from patients/team
· Ability to identify problems and recommend solutions
· Ability to read, write and communicate effectively orally and in writing
· Basic computer skills including previous work with an electronic health record (EHR) and Excel spreadsheets.
This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.
May 31, 2023