Chronic Care Management Nurse in Lawrenceville, GA at Prestige Staffing

Date Posted: 1/9/2020

Job Snapshot

Job Description

JobID: 23913

JOB OVERVIEW: The Chronic Care Management Nurse performs care management for chronically ill patients with chronic kidney disease. The Chronic Care Nurse works in collaboration and continuous partnership with chronically ill patients and their family/caregiver(s), clinic providers and community resources in a team approach to increase patients’ ability for self-management and shared decision-making.


  • Responsible for registry of chronic care management (CCM) patients.
  • Validates enrollment of CCM patients, based on patient diagnoses.
  • Complies with documentation requirements of the Chronic Care Management program by carrying out the care plan with the patient, family/caregiver(s) and providers and recording in the EHR.
  • Monitors adherence to care plans, evaluate effectiveness, monitors patient progress in a timely manner and facilitates changes as needed.
  • Creates an ongoing process for patient and family/caregivers(s) to determine and request the level of care coordination support they desire.
  • Facilitates patient access to appropriate medical and specialty providers.
  • Educates patient and family/caregiver(s) about relevant community resources.
  • Assist with the identification of “high-risk” patients (the chronically ill and those with special health care needs), and assist on the enrollment of these to the patient registry.
  • Coordinates continuity of patient care with external healthcare organizations and facilities including from the primary care provider to a specialty care provider.
  • Supports patient self-management of disease and behavior modification interventions.
  • Provides patient health counseling, education and instruction.


  • Minimum 2 years of experience working with chronically ill patients ( kidney disease / nephrology )
  • Must be either an LPN or RN