Chronic Care Management (CCM) Nurse Job Summary: Through the Chronic Care Management department, the CCM nurse supports clinical workflow that integrates value-based performance criteria. The position collaborates with patients, families, providers, other caregivers and disciplines to create a structure of managed care for complex patients. CCM nurses help improve quality, promote safe clinical care, guide appropriate use of resources, and enhance the patient and family’s healthcare experience. This position supports the care delivery team and demonstrates teamwork within the Care Management department and across other departments. This is an office/desk-based position that involves telephonic patient outreach. Job Requirements Required Licenses: + Mississippi Licensed Practical Nurse + Current Mississippi License or a current compact license Minimum Work Experience: + Three years of clinical experience Required Skills Efficient use of electronic medical record, word document, and spreadsheet computer programs. Knowledge of clinical workflow, case management, and healthcare revenue cycle or population health management. Experience data collection and analysis preferred. Essential Functions Professional Responsibilities: + Consistently applies established care management principles + Responsible for coordinating quality care management on assigned medically complex patients + Collaborates with the primary care provider and/or other team members + Identifies and guides appropriate clinical resource utilization and helps coordinate patient referrals + Assesses discharge needs and coordinates discharge plans to meet patient and family needs + Screen for readmission risk and seeks assistance to reduce unplanned hospital readmissions + Supports clinical workflow for compliance with value-based performance metrics + Self-directed and able to take initiative and display ability to think independently and creatively. + Seeks continual knowledge development of UR, coding quality measures, payors and payment models + Knowledgeable of criteria for Medicare, Medicaid, HMO, and private insurance coverage + Work collaboratively with patients, families, and physicians to ensure high quality care, cost effective care + Work with leadership to ensure targets are met for the operating/financial management + Participates as an effective team member with other Care Managers, Social Workers, and clinical caregivers. + Supports physician workflow to integrate quality, customer satisfaction and efficiency metrics + Demonstrates secure and confidential access to protected health information. + Demonstrates compassionate and caring approach with patients and their families. + Assist with data collection, monitor and respond to outcome metrics for assigned patient population. Core Duties: + Adhere to all SCRMC policies and procedures and all performance standards + Demonstrates reliability by consistently reporting to work on time as scheduled + Assess safety risk and risk of hospital acquired conditions and mitigates risk in assigned patient population + Participates in department improvement and other activities + Demonstrates competency in performance of relevant clinical skills Interaction Skills Effectively communicate verbal and written; negotiation; conflict resolution; interdisciplinary collaboration, customer service attitude, ability to provide accurate instructions and education.