Chronic Care Nursing

Taylor Rockaway with nominators

The Chronic Care Case Manager (CCM) RN will work with the patient’s provider and team to enhance efficient care.  Using effective self-management strategies to include goal setting, action planning, problem solving and follow up, The CCM RN will emphasize the patient’s central role in managing his or her health. Regular, proactive, planned visits and phone calls will be carried out to help individuals maintain health and provide resources to enhance optimal chronic disease management. Additionally the CCM RN will conduct Medicare Annual Wellness exams, Transitional Care Management, and provide triage advice to established patients, and assist the provider teams with nursing functions as needed. 

Learn more…

JOB PURPOSE:  To improve the health and well being of our communities.

RESPONSIBILITIES:

  • Schedules appointments and follow-ups as the patient’s condition requires, answer questions and provides patient education regarding their medical condition.
  • Screens and responds to patient phone calls, directing to primary care provider as needed.
  • Furnishes medical advice per collaborating providers. Schedules appointments based on necessity, by offering the earliest appointments available for each provider.
  • Schedules urgent visits as appropriate.
  • Enters necessary information into the EHR.
  • Accurately documents the encounter with the patient in the EHR. Reviews health records of identified chronic disease patients and adheres to disease specific treatment guidelines and objectives.
  • Order appropriate testing/referrals as needed and sends the information to the PCP for verification.
  • Tracks completion of testing/referrals and organizes data.
  • Implements process improvement or quality improvement initiatives to maximize outcomes.
  • Maintains confidentiality of all patient information.
  • Adheres to clinic policies and safety practices.
  • Performs a variety of tasks and other duties as assigned.
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Now Hiring Chronic Care Case Manager Nurses

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Living in Rifle, Colorado

You love what you do, now you can love where you do it. Our location is central to world-class ski resorts, mountain biking, ice climbing, snowmobiling, hunting, gold medal fishing and more!

Comprehensive Benefits Package

Grand River Health proudly offers a best in class, comprehensive benefits package that greatly exceeds market average.

CCM team at Clinic West

Thank you for considering Grand River Health for your career.  We take pride in a commitment to patient care that can help advance our mission, vision, and keys to excellence. 

  • OUR MISSION is to improve the health and well-being of the communities we serve.
  • OUR VISION is to be our communities’ first choice in quality healthcare.
  • OUR THREE KEYS TO EXCELLENCE are clinical excellence, patient & community satisfaction, and financial health & stewardship of resources.

Grand Rover Health’s main hospital campus is located in Rifle, Colorado just 23 minutes west of Glenwood Springs and 1 hour east of Grand Junction.  The city of Rifle offers year round recreation with everything the outdoor enthusiast can imagine – all located in the scenic Western slope of Colorado.  Grand River Health proudly offers a best in class, comprehensive benefits package that greatly exceeds market average.