Job Posting

Chronic Care Mgmt. Coordinator - Clinic
Chronic Care Management is a critical component of care that contributes to better health outcomes and higher patient satisfaction. The Chronic Care Management Coordinator provides patient-centered care that promotes management of patient needs across the healthcare continuum. Facilitates improvement in the overall quality, completeness, and accuracy of clinical documentation. Assists to prevent unnecessary hospital admissions and emergency room visits by providing education and guidance regarding proactive management of chronic healthcare needs. This unique service offers the opportunity to provide an enriching environment that demonstrates compassion and support to those patients suffering with chronic health conditions.

• Conduct monthly phone interviews with patients enrolled in to the Chronic Care Management Program within our medical practice.
• Building a supportive relationship with patients while providing care coordination support that will ensure access to appropriate services for their health needs.
• Design a patient-centered comprehensive chronic care management plan: set health goals with patients to promote self-management to optimize health and wellness. Document updates to the plan on a monthly basis.
• Review compliance with medical treatments including medication adherence; review side effects and tolerance of treatment plan. Assist patients with medication self-management; support prescription refill procedures with local pharmacies.
• Coordinate care for patients within the medical practice including appointment scheduling and cancellation management. Assist patients with setting up new appointments with referred outside providers.
• Offer health behavior recommendations and counselling support including nutritional, behavioral and psychosocial modifications to optimize health outcomes. (For example: smoking cessation, weight-loss, mental health, elder care and community referrals)
• Communicate with PCP any significant changes, patient concerns or any updates on patient status.
• Reviews Rural Health Clinic documentation for content, coding and completeness to ensure adherence to all local, state and federal regulations.
• Works in collaboration with Swing Bed Coordinator to ensure adequate case management of hospitalized patients enrolled in the FRHS Chronic Care Management Program.
• Carries out other projects or special assignments as assigned.

Education: South Dakota LPN or RN License is required.

Work Experience: Experience in Case Management and rural healthcare preferred.

A minimum of three to five years of experience in healthcare.

Additional Information
Position Type : Full Time
Shift : Day
Hourly Wage: $24.75 - $36.05 per/hour

Contact Information
Phone: 605-745-3159 ext 2329

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Fall River Health Services is a non-profit corporation of professional team members committed to excellent, quality and patient focused healthcare for the whole person. We provide for the physical, emotional, and spiritual needs of the individual, family, and significant others. We are committed to our patients, employees and our public.