Evergreen Family Medicine is committed to providing excellent care for your family with clinics in Roseburg, Sutherlin, and Myrtle Creek, Oregon. Evergreen Family Medicine serves outpatient needs, including Urgent Care, Family Practice, Women’s Health, Occupational Health, and school-based telehealth.
Evergreen Family Medicine is a Drug Free Workplace. All candidates that are offered employment will be required to pass a pre-employment drug screen and background check.
The Chronic Care Manager provides chronic care/clinical case management services aimed at enhancing patient-centered care and maximizing outcomes across the patient care continuum. Case management services include patient advocacy, monitoring patient care to ensure progress toward desired outcomes, addressing patient and family needs, resolving obstacles to effective care, and implementing disease-modifying interventions.
Responsibilities and Duties:
- Maintains confidentiality according to HIPAA regulations and EFM policies.
- Adheres strictly to EFM departmental standards and policies, including state and federal regulations.
- Communicates effectively and professionally with coworkers, managers, and patients via phone, email, or in person.
- Coordinates the case management process from the patient’s admission to discharge and follow-up care, including ER follow-up care.
- Identifies patients who are suitable for chronic care/case management intervention and seeks authorization for services.
- Assesses needs of patients/family, coordinates care and resources, and plans, develops, and implements appropriate patient care goals.
- Monitors and documents quality of care to ensure patient care plan goals are appropriate and understood.
- Identifies delays in service requests or treatments and communicates them to the healthcare team.
- Establishes measurable chronic care/case management goals that promote cost-effective, high-quality outcomes.
- Provides and/or assists in diabetic education, smoking cessation, and wound care management.
- Visits patients in care facilities and performs Chronic Care Management Services.
- Performs other duties as assigned.
Qualifications and Skills:
- High School Diploma or equivalent.
- Degree, license, or certification in an appropriate field of study with two years of professional experience in a clinically related area.
- Communication, interpersonal, clerical, and organizational skills necessary to complete job duties.
- Ability to handle the confidential aspects of the work.
- The ability to type at least 40 wpm and activate/operate computers and office equipment.
Physical Requirements:
- Prolonged periods sitting at a desk and working on a computer.
- Frequent walking, using hands and fingers, handling or feeling, and reaching forward with hands and arms.
- Occasionally required to sit, stoop, kneel, or crouch.
- May be exposed to patients with infectious diseases.
- Must be able to lift up to 35 pounds at times.
Our Culture and Values:
The needs of our patients come first: S.P.I.R.I.T
- Stewardship
- Patient & Population Focused Health Care
- Integrity
- Respect
- Innovation
- Teamwork
Benefits:
- Health, Dental, Vision benefits
- Life Insurance
- 401k with a company match up to 6%
- Paid Time Off
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