Chronic Care Manager Job in Uniontown 15401, Pennsylvania US

Chronic Care Manager – Preferred Primary Care Physicians, one of Pittsburgh’s largest private physician groups, is seeking a full time Care Manager for an office located in Uniontown, PA. Successful candidate will work with team members, practice staff, and physicians to improve outcomes for patients with chronic conditions such as diabetes. Duties will include coordinating preventive services, referrals to outside agencies, and follow-up care. Excellent patient relations skills are essential. Computer skills are critical and experience with electronic health records a plus. Organizational skills ability to work independently necessary. RN or LPN required. Case Management or Home Care experience preferred. Some travel between local physician offices possible. This is a very exciting opportunity to be at the forefront of primary care delivery. Competitive salary and benefits. Submit cover letter, resume, and salary requirements to careers@ppcp.org or fax to 412-531-2845. EOE m/f/d/v

Essential Duties and Responsibilities: 

·         Identifies and risk stratifies patient focus population using disease, utilization, self management, financial, and transition of care risk factors.
·         Collaborates with Physicians, Quality Manager, and Quality Committee to improve adherence to evidence based guidelines, implement programs aligned with guidelines, and develop strategies to overcome barriers limiting success in achieving best practice parameters. 
·         Educates patients and families about managing their health conditions.
·         Provides educational materials and information on available community resources to patients.
·         Collaborates with patients and families to establish and work toward appropriate self management goals.
·         Progress reporting to Quality Manager, Quality Committee and others as directed.
·         Coordinates with external disease management organizations.
 
Job Responsibilities:
·         Identify and risk stratify patient focus population using disease, utilization, self management, financial, and transition of care risk factors.
·         Work with Care Management Coordinator and office staff to generate reminders for preventive care and follow-up, identifying patient population requiring more in-depth management.
·         Educate patients and families on managing their health conditions.
·         Identify and address barriers to achieving positive outcomes.
·         Educate and use non-physician staff to manage patient care.
·         Track patient outcomes for revisions in strategies.
·         Utilize evidence based guidelines to prompt physicians.
·         Utilize standing orders for ordering medication refills, ordering tests and routine preventive services and arranging follow-up appointments.
·         Assist with patients’ navigation through the health care continuum.
·         Coordinate with external disease management organizations, identify and collaborate with external resources to support educational efforts in the community for patients.
·         Provide support to Quality Committee in managing patient populations.