The CCM nurse supports patients with multiple chronic conditions through telephone and electronic outreach. They collaborate with primary care providers, nursing care managers, and other healthcare professionals to ensure continuity of care outside of traditional office visits. The goal is to improve patient outcomes, promote adherence to care plans, and reduce hospitalizations and ER visits.
Key Responsibilities:
Telephone Patient Management
Care Coordination:
Management including developing care plans, coordinating referrals, prescription refills, ordering of labs/DI.
Track and resolve outstanding orders, labs, and procedures.
Patient Engagement:
Assist patients in setting goals for self-management.
Provide follow-up management with patients and/or family members to ensure compliance with their care plan.
Documentation and Communication:
Document all interactions in the EMR (Eclinical Works)
Collaborate with the healthcare team to modify care plans
Must be licensed