Chronic Care Coordinator - RN (Remote)

Position Summary The Chronic Care Coordinator (CCC) will demonstrate all competencies listed below along with maintaining strong relationships with staff and CCM Team to successfully carry out these duties; The Care Coordinator will serve as a patient liaison between different specialty departments both internally and externally.
In additional, the Care Coordinator will continuously identify and address needs of patients, caregivers and families with multidisciplinary team.
Essential Functions and Responsibilities Manages individual caseload of patients assigned by Chronic Care Program Manager Provides monthly non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions.
Creates a patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental needs.
Manages care transitions between and among health care providers and settings.
Including referrals to outside providers.
Follow up after emergency department visit and after discharges from hospital, skilled nursing facilities and/or other healthcare facilities.
Coordinates care with home and community based clinical service providers.
Identifies inventory of resources available to patient/caregiver/family.
Communicates patient’s needs/concerns to multi-disciplinary team and coordinates care appropriately.
Documents monthly contact/Care Management Notes in electronic health record.
Submits monthly billing reports to Chronic Care Program Coordinator.
Attends monthly team meetings as scheduled.
Performs other duties as assigned.
Qualifications Education (Including Licenses and Certifications): Licensed as Registered Nurse or Licensed Practical Nurse in the State of North Carolina.
BSN or enrollment in BSN program preferred.
Experience: 2 years Case Management experience preferred Day Shift, Monday - Friday (no weekend or holidays required) 40hrs/week