The CCM Specialist works with Primary Care Providers (PCP), care center staff, and Nurse Care Managers to provide telephonic management of patients with multiple chronic conditions and increased risk factors to ensure excellent care is provided outside of office visits.
Responsible for facilitating quality care in accordance with established clinical practice guidelines and protocol and PCP direction.
Fosters patient engagement and adherence to plan of care to achieve evidence based clinical objectives and goals specific to chronic conditions and preventive health measures.
Job Responsibilities:
Manage patient care telephonically, through the following methods: Review of the patient’s medical, functional, and psychosocial needs Medication reconciliation with review for adherence Encourage and facilitate timely receipt of all recommended preventive services Reinforce disease self-managem...