Location: Stoney Batter Family Medicine

Position: CCM Coordinator / Manager

Schedule: 8-hour shift; Monday to Friday; Flex time available

Benefits: Health insurance; Paid time off

Stoney Batter Family Medicine Associate P.A. CCM program provides quality outreach for patients with multiple chronic condition. On a daily basis, CCM Case Manager will coordinate care, outreach to patients providing care management services and accurate and timely documentation.

Essential Duties: The duties listed below are the essential functions of this position, and they may change as the needs of the company demand. All CCM Coordinator / Care Managers are expected to do what is necessary to get the work done and to cooperate fully with their supervisor’s requests for additional or altered duties.

 Identifies and implements the appropriate level of intervention based upon the member’s needs and clinical progress

 Maintain proper documentation including

o. Patient notes

o Messaging

o Care Plans

o Medication Reconciliation

o Scheduling notes

 Coordinate with Provider on

o Goals

o Patient Needs

o requirements

 Shares goals with the member and family as appropriate

 Schedules follow up calls as necessary

 Keeps a calendar and f/u on issues

o If meds were changed

o BP calls back in a week

o Depression meds call back in a week

 Documents progress towards meeting goals and resolving problems

 Coordinates care and services with other offices as needed

 Schedule visits

 Assist provider on AWV’s by completing the assessment portion

 Orders DME

 Provide virtual visit to patient when necessary

 Check voicemails multiple times a day

 Support other case managers at times of absences including

o Patient Contact

o Call coverage

o Messaging

 Participate in regularly scheduled meetings as needed

 Access Aledade APP daily for

o Admission data on covered patients to avoid readmissions

o Care Gap

 Graduates and defers pts when needed

 Other duties as assigned

Please note this position is posted on behalf of our partner practices. This individual will be working at the specific practice that is mentioned in the above details and will not be a direct employee of Aledade, Inc. so will therefore not be eligible for the benefits available to Aledade employees.