Full-Time
Licensed Practical Nurse
Chronic Care Management
Medical University of South Carolina
Health sciences university in Charleston, SC
No salary listed
South Carolina, USA
Remote
Category
 Medical, Clinical & Veterinary |
|---|
Required Skills
Epic (EHR)
Electronic Health Records (EHR)
Care Coordination
Basic Life Support (BLS)
Patient Education
Get referred to Medical University of South Carolina
See people who can refer or advise you
Requirements
- Active Licensed Practical Nurse licensure in good standing is required, with South Carolina licensure preferred.
- Basic Life Support certification is required if applicable to the role.
- Strong communication and interpersonal skills are required.
- The role requires the ability to assess patient needs and apply clinical judgment appropriately.
- Proficiency in electronic health record documentation and care coordination workflows is required; experience with Epic Systems is preferred.
- Knowledge of chronic disease management and population health principles is required.
- The role requires the ability to manage a high-volume patient panel efficiently.
- Strong organizational and time management skills are required.
- The role requires the ability to work independently within established workflows and standard operating procedures.
- The role requires the ability to route communications appropriately to providers or clinical support teams.
Responsibilities
- Conduct monthly telephone outreach to assigned Chronic Care Management patients.
- Complete at least 20 minutes of non-face-to-face care management services per patient per calendar month.
- Make at least two outreach attempts for patients who are not reached.
- Assess patient status, including changes in condition, symptoms, or care needs.
- Review and reinforce individualized care plans and patient goals.
- Support medication adherence and identify potential medication concerns.
- Identify and address barriers to care, including transportation, medication access, and social needs.
- Assist with scheduling appointments when clinical evaluation is needed.
- Escalate clinical concerns to appropriate clinical support staff or providers according to workflow standards.
- Document all interactions accurately in the electronic health record and track time for billing compliance.
- Collaborate with providers, care teams, and community resources to ensure continuity of care.
- Provide education on chronic disease management and preventive care.
- Encourage patient participation in primary care and adherence to treatment plans.
- Monitor for signs of deterioration and escalate concerns appropriately.
- Support transitions of care when applicable.
- Promote patient self-management and engagement in their health.
Desired Qualifications
- Prior experience in care coordination, case management, ambulatory care, or chronic disease management.
- Experience working with high-risk or chronic-condition populations.
- Experience with Epic Systems.
Medical University of South Carolina is a public academic health sciences university in Charleston, South Carolina. It offers bachelor's, master's, doctoral, and professional degrees through six colleges in dental medicine, graduate studies, health professions, medicine, nursing, and pharmacy.
Company Size
N/A
Company Stage
N/A
Total Funding
N/A
Headquarters
N/A
Founded
N/A
Get referred to Medical University of South Carolina
See people who can refer or advise you