Chronic Care Management- Nurse

Our office is located in Buffalo, New York but work can be on a Remote / Work From Home - Flexible Scheduling basis (MUST RESIDE IN NYS)

Mobile Healthcare Partners is a home-based primary care practice that specializes in geriatric healthcare, serving New York State.

This role will be providing telephonic Care Management for patients throughout the health system under the direction of a patient’s provider. The CCM nurse utilizes nursing process to evaluate patient needs over the telephone and provide guidance and education to patients, adhering to organizational policies, procedures and guidelines. Provides high risk patients with chronic disease management and liaises between the patient, patient’s family or caregiver, provider, provider’s office, hospital, home care agency etc. This position is telephonic care coordination as directed by the patients provider.

Responsibilities:

• Cooperatively develop and integrate patient centered provider care plan and goals with the client/family and other providers
• Work collaboratively with team members to provide outreach and engagement with the patient
• Work closely with in-office providers/staff members to:
  1. Provide patient education to assist with self-management
  2. Identify gaps or barriers in treatment plans
  3. Coordinate care enrolled patients including scheduling appointments
  4. Coordinate referrals
  5. Coordinate community resources as needed (ie: home health, DME etc)
  6. Educate members on disease processes
  7. Encourage members to make healthy lifestyle changes
• Actively maintain assigned caseload of patients
• Make outbound calls to assess members current health status
• Receive and respond to telephone calls from patients. Collecting health data and providing medical guidance under the direction of the patients provider
• Document calls according to established guidelines
• Connects patient’s care team together with updated information as received
• Participation in education and in-service programs
• Performs on-call for region that you are assigned
• Additional duties as assigned

Qualifications:

• Unrestricted and current license to practice as LVN/LPN/RN with a New York State license.
• 3 years of experience within Care Management setting or Case Coordinator either in the homecare, inpatient, physician practice or in-home case management setting
• 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 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
• Demonstrates progressive proficiency with the utilization of available computer technology, including typing skills
• Demonstrates; leadership, communication, interpersonal and problem-solving skills
• Experience working with Electronic Health Record (EHR)
• Ability to sit and work at a computer for extended periods of time
• 60 words per minute typing
• Bilingual in Spanish preferred but not required

Benefits Include

Work From Home setting

Monday through Friday Day schedules

Benefits after 30 days

Company paid Short Term Disability

7 Paid Holidays

3 weeks of Time Off