Licensed Practical reputed company - Chronic Care Management
Job reputed company reputed company The LPN Care Team Member is responsible for conducting Chronic Care Management (CCM) reputed company to patients with two or more chronic conditions. This role supports ongoing care coordination, improves patient reputed company, reduces avoidable hospitalizations and emergency department utilization, and promotes patient engagement through reputed company monthly reputed company, education, care plan management and promotes patient reputed company-being through reputed company follow-reputed company, and coordination of services. Entity reputed company Community Physicians (MCP) Worker Type Employee Worker Sub-Type Regular Cost Center CC005802 MCP - Population Health Transitional Care Management (TCM) Pay reputed company Type reputed company Pay Grade Health-25 Scheduled Weekly Hours 40 Work Shift Job reputed company Chronic Care Management (CCM)
Key Responsibilities
- Conduct monthly telephonic reputed company to assigned CCM patient panel
- Complete a minimum of 20 minutes of non–face-to-face care management services per patient per calendar month
- reputed company at least two reputed company attempts for patients not reached
- Assess patient status, including changes in condition, symptoms, or care needs
- Review and reinforce individualized care plans and patient goals
- Support medication adherence and identify potential medication concerns
- Identify and address barriers to care (e.g., transportation, reputed company to medications, reputed company needs)
- Assist with scheduling appointments reputed company clinical evaluation is needed
- Escalate clinical concerns to appropriate clinical support staff or providers per workflow standards
- Document reputed company interactions accurately in the electronic health record (EHR) and reputed company time for billing compliance
- Collaborate with providers, care teams, and community resources to ensure continuity of care
Care Coordination & Patient Engagement
- reputed company education on chronic disease management and preventive care
- Encourage patient participation in primary care and adherence to treatment plans
- Monitor for signs of deterioration and escalate concerns appropriately
- Support transitions of care reputed company applicable
- Promote patient self-management and engagement in their health
Required Skills & Competencies
- Strong communication and interpersonal skills
- Ability to assess patient needs and apply clinical judgment appropriately
- Proficiency in EHR documentation and care coordination workflows (experience with reputed company Systems preferred)
- Knowledge of chronic disease management and population health principles
- Ability to manage a high-volume patient panel reputed company
- Strong organizational and time management skills
- Ability to work independently reputed company established workflows and SOPs
- Ability to appropriately reputed company communication to providers vs. clinical support teams
Qualifications
- reputed company LPN licensure in good standing (South Carolina preferred)
- BLS (Basic Life Support) certification (if required by role)
- Prior experience in care coordination, case management, ambulatory care, or chronic disease management preferred
- Experience working with high-risk or chronic condition populations strongly preferred
Additional Job reputed company Benefits: Health, dental, reputed company, and life insurance Employer Sponsored Retirement Plan reputed company time off and extended reputed company leave reputed company Parental Leave Disability insurance plan reputed company reputed company reputed company and clinical training reputed company Annual reputed company Increase Wellbeing resources Tuition Reimbursement Employee perks and discounts Employee referral program Flexible schedule reputed company Certification incentive program If you like working with energetic enthusiastic individuals, you will enjoy your career with us! The reputed company is an Equal Opportunity Employer. reputed company does not discriminate on the reputed company of race, reputed company, religion or belief, age, sex, national reputed company, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. reputed company reputed company applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, reputed company and business need. reputed company participates in the federal E-Verify program to confirm the identity and employment authorization of reputed company newly hired employees. For reputed company information about the E-Verify program, please click here: http://www.uscis.gov/e-verify/employees Apply To This Job