Location: Stoney Batter Family Medicine
Position: CCM Coordinator / Manager
Schedule: 8-hour shift; Monday to Friday; Flex time available
Benefits: Health insurance; Paid time off
Stoney Batter Family Medicine Associate P.A. CCM program provides quality outreach for patients with multiple chronic condition. On a daily basis, CCM Case Manager will coordinate care, outreach to patients providing care management services and accurate and timely documentation.
Essential Duties: The duties listed below are the essential functions of this position, and they may change as the needs of the company demand. All CCM Coordinator / Care Managers are expected to do what is necessary to get the work done and to cooperate fully with their supervisor’s requests for additional or altered duties.
Identifies and implements the appropriate level of intervention based upon the member’s needs and clinical progress
Maintain proper documentation including
o. Patient notes
o Messaging
o Care Plans
o Medication Reconciliation
o Scheduling notes
Coordinate with Provider on
o Goals
o Patient Needs
o requirements
Shares goals with the member and family as appropriate
Schedules follow up calls as necessary
Keeps a calendar and f/u on issues
o If meds were changed
o BP calls back in a week
o Depression meds call back in a week
Documents progress towards meeting goals and resolving problems
Coordinates care and services with other offices as needed
Schedule visits
Assist provider on AWV’s by completing the assessment portion
Orders DME
Provide virtual visit to patient when necessary
Check voicemails multiple times a day
Support other case managers at times of absences including
o Patient Contact
o Call coverage
o Messaging
Participate in regularly scheduled meetings as needed
Access Aledade APP daily for
o Admission data on covered patients to avoid readmissions
o Care Gap
Graduates and defers pts when needed
Other duties as assigned