Chronic Condition Manager - RN - Anderson, SC

About the role

Facilitate, develop, monitor, measure, and report on wellness and chronic disease prevention and management programs that complement the Health Center maintained and coordinated by Marathon Health. The Chronic Condition Manager will educate, counsel, and coach patients on how to prevent and/or manage chronic disease in face-to-face, virtual and/or telephonic formats, as well as in one-on-one and/or group settings. The CCM may also be responsible for developing educational materials. The CCM may be asked to coordinate efforts among all client vendors to provide cohesiveness of services and to better engage the client population. These duties are carried out for a specific client at its various locations. ESSENTIAL DUTIES & RESPONSIBILITIES Facilitates chronic condition management and prevention programs, including but not limited to: Diabetes Management, Diabetes Prevention, Hypertension Management, Hyperlipidemia Management, COPD, Asthma, Obesity and Cardiovascular Disease. Programs include clinical, educational, and health coaching components Develops individualized interventions designed to improve and maximize health outcomes Conducts thorough and objective evaluations of the patients' status, including psychosocial, physical, financial, and educational needs, prognosis, and past and present treatment course and services Identifies and enrolls individuals that qualify for chronic condition management programs Establishes supportive and confidential relationships with patients Assesses patients' clinical and educational knowledge of chronic condition, readiness to change behavior and individualizes program/s based on needs Collaborates with other members of the healthcare team, such Nurse Practitioners, Physician Assistants, Medical Doctors, Health and Wellness Coaches, to optimize care and solve problems Conducts outreach via phone, email and regular mail Provides face-to-face, virtual and telephonic lifestyle and behavior-related health coaching in both individual and group settings Reviews HRA results, if applicable, and provides education and counseling to patients based on risk factors Follows workflow and policy guidelines for documentation in the electronic medical record, including the utilization of predictive modeling and behavior change analytics tools Applies critical thinking skills and problem-solving techniques to the condition management process Participates in the analysis of available data, review of reports, and strategy for enrollment of members to condition management programs Performs in-person, virtual, telephonic, and/or electronic proactive outreach to members that are eligible for disease management programs, as well as to unengaged members Utilize Evidence Based Medicine in clinical decision making particularly with medication management, diagnostic and lab testing orders, and providing support/education to patients in making healthy lifestyle & behavioral changes. Completes accurate, timely and thorough documentation in EMR system. Support the mission, vision, and values of Marathon Health. Participate in and complete all mandatory Marathon Health trainings and meetings and comply with organizational policies and procedures. Participates in education sessions coordinated by Marathon clients for their respective, eligible patient population Coordinates efforts with other vendors (carriers, EAP, etc.) to inform client population of all available resources Communicates with Marathon Corporate and/or carrier to provide compliance-related information and necessary documentation Directs patients to onsite providers, primary care physicians, and/or specialists, as needed Maintains current knowledge of disease processes, available resources, and treatment options appropriate to patient populations. Performs other duties as assigned