Responsibilities
- Record all CCM and APCM activities in the Electronic Medical Record following CMS guidelines.
- Precisely log time spent on CCM tasks.
- Help identify patients who qualify for CCM or APCM enrollment.
- Examine previous CCM and APCM documentation to maintain care continuity and prevent duplicate services.
- Support annual and interim updates of personalized patient care plans.
- Assist patients during transitions from hospital or other acute care settings.
- Ensure every APCM and CCM patient has a tailored care plan addressing their specific needs, preferences, and goals, including medication management, health education, lifestyle changes, and specialist coordination.
- Follow up on referrals, diagnostic tests, and specialty consultations.
- Review medical records to identify care gaps and preventive health needs.
- Reconcile medications using Medication Administration Records and provider documentation.
- Update problem lists, diagnoses, allergies, immunizations, and patient demographics as needed.
- Assist with documentation for quality measures and value-based care initiatives.
- Participate in audits and quality improvement projects.
- Monitor and evaluate the APCM and CCM program's effectiveness using data and metrics to track goal progress.
- Ensure all work under the APCM and CCM program is meaningful, high-quality, and compliant with regulations and standards.
- Collaborate with providers, medical assistants, patient representatives, nursing staff, and administrative personnel.
- Apply critical thinking and creativity to develop innovative care management approaches.
- Promote a patient-centered culture focused on quality, compassion, and continuous improvement.
- Help the CCM Coordinator achieve monthly program goals and enhance patient outcomes.
- Deliver care in a non-judgmental, non-discriminatory manner that respects patient and family diversity, preserving their autonomy, dignity, and rights.
- Complete assignments as directed by the supervisor.
Requirements
- Graduation from an accredited Bachelor of Science in Nursing program with an active Registered Nurse license, or a high school diploma or equivalent with graduation from an accredited Licensed Practical Nurse program.
- Excellent verbal and written communication skills.
- Strong organizational abilities.
- Proficient documentation and computer skills.
- Strong commitment to providing quality medical care for medically underserved individuals.
- Ability to work independently while managing multiple priorities.
- Proven ability to work productively in highly collaborative settings and to seek and synthesize input from multiple stakeholders.
Nice to Have
- At least one year of nursing experience.
- Experience working with individuals with Intellectual and Developmental Disabilities, including coordinating medical, behavioral health, residential, and community-based services.
- Experience in primary care, case management, care coordination, population health, or chronic disease management.
- Knowledge of Electronic Medical Records systems.
- Strong oral, written, and organizational skills.
- Prior experience coordinating medical record activities in a busy medical office or healthcare center.
Work Arrangement
Hybrid — health centers as assigned
Other
- Prolonged periods of sitting and computer work.
- Monday through Friday, as assigned.
- Flexibility to work in both health centers as assigned.
- Role can be done as hybrid, in-person, or remote based on health center needs.
- On-site attendance for the first six months to complete training and gain a thorough understanding of healthcare processes and workflows.
