Chronic Care Lead Nurse

1.Fulfill the Avenue health care mission to provide high quality care that exceeds our client expectation with the goal to deliver through courteous, respect and compassionate manner.

2.Responsible for registry of chronic care management (CCM) to patients.

3.Validates enrollment of CCM patients based on provider request

4.Comply with documentation requirements of the Chronic Care Management program by carrying out the care plan with the patient, family/caregiver(s) and providers and recording in the EMR.

5.Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, and facilitates changes as needed.

6.Creates an ongoing process for patient and family/caregivers(s) to determine and request the level of care coordination support they desire.

7.Facilitates patient access to appropriate medical and specialty providers.

8.Coordinates transition of inpatient to outpatient care in an effort to decrease readmission rates

9.Work closely with in-office providers to manage the day to day calls involving: symptom control, medication management, and provide patient and family education

10.Educates patient and family/caregiver(s) about relevant community resources.

11.Assist with the identification of “high-risk” patients (the chronically ill and those with special health care needs), and assist on the enrollment of these to the patient registry.

12.Coordinates continuity of patient care with external healthcare organizations and facilities including from the primary care provider to a specialty care provider.

13.Supports patient self-management of disease and behavior modification interventions.

14.Provides patient health counseling, education and instruction.

15.Any other duty assigned by your immediate supervisor in line with the job description.