Chronic Care Manager

The Bedford-Stuyvesant Family Health Center (BSFHC) is a Federally Qualified Health Center (FQHC) that serves all of the primary health care needs of families in the heart of North and Central Brooklyn. Our mission is to provide the most professional courteous and highest quality health care with dignity to those we serve especially the undeserved population without regard for ability to pay.

Position Summary:

The Chronic Care Managers primary responsibility is to assist in the overall management of the health centers high risk patients particularly those with chronic diseases. This is conducted through a population-based approach as well as individual interventions such as individual health and behavioral assessments to identify prevention treatment or management intervention opportunities.

Duties and Responsibilities include but not limited to:

Evidence-based Chart Review:

• Reviews charts of patients scheduled to be seen by a provider by applying BSFHCs approved evidence based guidelines and establishing a standardized plan of care. Measure(s): Asthma - Current Severity Assessment Asthma Appropriate Therapy Diabetes HbA I c Diabetes Glucose Testing Cardiovascular Blood Pressure Checks Prevention Colon Cancer Screening Prevention Smoking Education Nutritional Guidance Prevention Vaccinations.

Patient Calls & Correspondence:

• Returns patient calls. Contacts patients to report test results complete referrals change medications or care plan as well as to notify patients of their upcoming appointment (pre-visit phone calls) prescriptions called into the pharmacy and follow up on Self-Management Goals in a timely manner.

Patient Education:

• Conducts individual or group based education counseling or self-management goal setting sessions.

Documentation & Reporting:

• Provides routine and timely documentation of all core process work activities including but not limited to evidence-based chart reviews patient calls & correspondence and patient education activities.

Access & Efficiency:

• Promotes teamwork within the microsystem to improve patient access and the efficiency of the team and the site as a whole.

Education Licenses and/or Certifications Experience Requirements:

• Relevant experience in care management (e.g. group sessions) desired. Ability to interact with physicians and other health care professionals in a professional manner. Proficient in Microsoft Office and Excel.
• Licensure/Certification: LPN with relevant experience

Other Related Skills/Experience:

• Must be flexible with scheduling
• Maintain HIPPA patient/employee confidentiality
• Knowledge of EMR systems a must
• Bilingual ability a plus.
• Excellent interpersonal skills must demonstrate professionalism courteous and respectful attitude in dealing with patients team members families and significant others
• Display courtesy tact and patience with all members of the team members and extended community
• Ensure that all patients and visitors receive personalized prompt attention and are treated with receptiveness dignity and respect
• Provide instructions to the patient upon discharge as per instructed by the providers
• Strong organizational skills and ability to think clearly and to work in a busy clinic
• Strong skills in a Microsoft Outlook and Word
• Excellent verbal and written communication and time management skills

Benefits Overview: We offer attractive compensation with comprehensive benefits including Profit Sharing Plan Medical 401(k) and Long-Term Disability Transportation Plan Generous Paid Vacations and Holidays.

Starting Salary $25 - 30 per hour based on experience

BSFHC IS AN EQUAL OPPORTUNITY EMPLOYER