Chronic Care Program Supervisor (Remote)

Position Summary

The Care Management Program Supervisor will demonstrate all competencies listed below along with maintaining strong relationships with PMC staff to successfully carry out these duties; the Program Supervisor will oversee the CCM Program and its staff: all Care Coordinators. He or she will attend administrative meetings as scheduled and will also facilitate monthly CCM Staff Meetings. The Supervisor will oversee established metrics, reports, processes, and programmatic improvements for both the care management and transitional care management teams.

Essential Functions and Responsibilities

• Supervises Care Coordinators and Transitional Care Coordinators.

• Processes referrals for appropriateness and distributes to nurses, managing caseload numbers.
• Responsible for timecards, PTO, coordinating coverage.
• Performs annual reviews in a timely manner for direct reports.
• Attend administrative meetings involving Primary Care and Value Based Care. Primary care nurse staff meetings as needed.
• Work with manager on initiating process improvement, new program builds.
• Manages own individual caseload of assigned patients.
• Provides monthly non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions.
• Creates a patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental needs.
• Manages care transitions between and among health care providers and settings. Including referrals to outside providers.
• Follow up after emergency department visit and after discharges from hospital, skilled nursing facilities and/or other healthcare facilities.
• Coordinates care with home and community based clinical service providers.
• Consistently uses and guides staff’s usage on patient information portals such as CarePort, EPIC.
• Identifies inventory of resources available to patient/caregiver/family.
• Communicates patient’s needs/concerns to multi-disciplinary team and coordinates care appropriately.
• Documents contact/Care Management Notes in electronic health record.
• Performs other duties as assigned.

• Licensed as Registered Nurse in the State of North Carolina. BSN or enrollment in BSN program preferred.

• 2 years Case Management experience preferred