Chronic Care Management Specialist

About MedNOW:

MedNOW Clinics is a thriving and growing primary care organization in Colorado committed to delivering high-quality, comprehensive and coordinated care. Founded in 2010, MedNOW now has 12 locations and approximately 50 medical providers, 160 employees and 40,000 patients under our care. We strive to provide outstanding customer service and excellent communication for our customers.

MedNOW provides family medicine, internal medicine, addiction medicine, pain management, behavioral health, medical weight loss, dietician services, X-ray services, hormone therapy, immigration services, IV therapy, physical therapy and massage therapy.

Please learn more about us at www.MedNOWClinics.com.

Benefits for MedNOW Full-Time Employees:

-            Paid time off

-            401(k) with company matching

-            Health, Dental & Vision insurance

-            Ancillary insurance options

-            Family Discounts for MedNOW services

We promote long term employment through continuing employee education and advancement opportunities. Our managers and administrative teams work closely with all employees and use training manuals and guidelines to ensure all staff have the tools necessary to perform their job functions, learn and grow in line with individual needs and goals.

Job Duties & Responsibilities:

·        Supports comprehensive care management of Medicare patients in support of MedNOW Clinics (MedNOW) health-care team by providing twenty minutes of patient education and care coordination monthly to Medicare patients who have two or more chronic diseases. 

• • Outreach to eligible MedNOW patients to educate and enroll them in the Medicare Chronic Care Management (CCM) program.
  • Coordinates the creation of a person-centered, electronic care plan (Comprehensive Care Plan) based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues, with particular focus on the chronic conditions being managed).
  • Maintains Comprehensive Care Plans by reviewing and updating (if necessary) annually.
  • Ensure continuity of care with a designated member of the care team with whom the patient can schedule successive routine appointments.
  • System-based approaches to ensure timely receipt of all recommended preventive care services.
  • Medication reconciliation with review of adherence and potential interactions.
  • Oversight of patient self-management of medications.

• Provide health promotion services similar to the role of a health educator, such as providing training materials and teaching self-management skills pertaining to the patient’s goals identified in the Comprehensive Care Plan. 
  • Encouraging and supporting health education for patients and family/support persons.
  • Assessing the patient’s and family/support persons’ understanding of the patient’s health condition and motivation to engage in self‐management.
  • Coaching patients and family/support persons about chronic conditions and ways to manage health conditions based on the member’s preferences.
  • Linking the patient to resources for: smoking cessation, management of chronic conditions, self‐help recovery resources, and other services based on patient needs and preferences.
  • Using evidence‐based practices, such as motivational interviewing, to engage and help the patient participate in and manage their care.
  • Utilizing trauma‐informed care practices.

• CCM Specialist interfaces with patients and other stakeholders through a variety of mechanisms, including, but not limited to: 
  • Individual, face-to-face contacts through both appointment and warm hand-off contacts.
  • Telephone and other electronically mediated contacts; and
  • Contact outside of MedNOW Clincs to provide linkages to appropriate community resources based upon the patients’ identified needs and goals through the Health Action Plan. This could be a mobile unit for example.
  • Responsible for creating a patient case in Athena after every phone call and sending case to the PCP.

• During contacts with health-care team members at MedNOW and from other organizations, CCM Specialists reduce barriers to care in several ways including but not limited to: 
  • Preparing, printing and distributing the information necessary for care teams to engage in Pre-visit Huddles.
  • Maintaining regular communication with care team providers on patient care plan goals and progress.
  • Facilitating regular communication between patients and other health-care team members both inside and outside MedNOW.
  • Providing staff training and education sessions necessary to implement health education and care coordination services.
  • Participates in meetings and training as necessary to facilitate the above duties, including those geared toward implementing evaluation tools that determine the effectiveness of CCM Specialist functions.
• After patients follow up phone calls
• Monthly phone calls for 20 min minimum per month
• Enroll patients and acknowledgments
• Comm with providers on weekly updates or after patient calls
• Market to patients and our providers
• Trained in Athena to find patients turning 65
• File in as regular medical assistance

• Performs other duties as assigned.

Professional & Technical Knowledge:

• Possesses work-related skills at a higher level than completion of high school, including formal written and verbal communications skills, computational and computer skills, mathematical, technical or health care related knowledge frequently acquired through completion of a trade school, para-professional, or certificate type program.

• Requires at least one year of health care related work experience.

Technical Skills:

• Ability to prepare basic documents in Microsoft Word, including creating tables, charts, graphs and other elements.

• Ability to use Microsoft Excel to review and compile data, including the use of formulas, functions, lookup tables and other standard spreadsheet elements.

• Ability to create basic presentations in Microsoft PowerPoint.

Licenses & Certifications:

·        Certified Medical Assistant (CMA)

Communications Skills:

• Job duties require the compilation of information prepared in effective written form, including correspondence, reports, articles or other documentation.

• Effectively conveys technical information to non-technical audiences.