Join our team committed to the highest quality health care!
JOB RESPONSIBILITIES:
- The Chronic Care Program Manager is responsible for the growth and maintenance of the Care Coordination Program and
- Includes oversight and management of Chronic Care Management (CCM) staff and Chronic Care Department
- Supervise the development of care plans
- Recruitment and maintenance of patients enrolled in care management services;
- Assurance of the completion of the annual wellness visit and follow up on all elements of the preventative plan of care;
- Completion of discussions of advance care planning with patients.
- Providing management and support of care coordination staff, collaboration with interdepartmental staff, outreach, disease management/care management, care coordination/health promotion, education/training and motivational support to patients, referral sources and the community.
- As necessary, render CCM services
- Working with and representing Sixteenth Street Community Health Centers across multiple constituents and for the financial performance of the program.
- Ensure department staffing per productivity targets; interviews, hires, educates, trains, coaches, evaluates, and makes staffing assignments for care coordination staff.
- Demonstrate skills in effectively coordinating and monitoring care to promote quality and cost-effective outcomes.
- Analyzes clinical data generated from EHR/Registry system and identifies patients who have gaps in care and utilizes risk stratification intervention metrics for care coordination recruitment purposes.
- Remains current on industry trends, best practice operational models, and changing patient and provider needs. Provides coaching and training opportunities for CCM staff to do the same.
- Work to improve the quality of life of patients enrolled through supporting quality outcomes, smooth care transitions, coordination of care across the health continuum, encourage healthy lifestyle choices to reduce long term effects of chronic illness.
- Participate in quality improvement projects.
- Work synergistically with other clinical departments.
- Determine and connect with relevant community and/or health care resources to support solutions; provide educational tools to promote self-management.
- Provide outreach, disease management, education and other needed clinically based activities to patients managing various chronic health conditions and to referral sources and community.
- Act as a liaison between referral sources, facilities, and outside entities to prevent and/or resolve continuum of care issues
- Communicate with service delivery partners, providers, and other health professionals to provide care coordination to ensure the plan of care facilitates the efficient use of health care resources.
- Adhere to infection control safety guidelines and confidentiality policies.
- Fulfill organizational responsibilities as assigned which include: respect and promote patient's rights, respond quickly and appropriately to emergency situations and share problems relating to patients and/or team members with Manager or supervisor quickly.
- Provide safe, patient centered, compassionate and competent care.
- Attend training and meetings as required. Maintain annual competencies. Maintain CPR certification.
- Perform all other duties as assigned.
QUALIFICATIONS:
- RN, BSN preferred
- Solid background with Chronic Care Management. Understands related requirements and how to grow program.
- Previous work experience with educating patients and patient goal setting preferred
- Previous supervisory experience preferred.
- Ability to relate well to people from diverse ethnic and cultural backgrounds.
- Bilingual (Spanish/English) preferred.
- Ability to make critical decisions while following organizational policies and procedures.
- Ability to perform work accurately and thoroughly.
- Proficient ability to use a computer and electronic medical record, preferably EPIC and Compass Rose.
- Maintain patient, team member and employer confidentiality. Comply with all HIPAA regulations.
- Customer Service Oriented - Friendly, cheerful and helpful to patients and others. Ability to meet patients and others needs while following office policies and procedures.
- Ability to adapt easily to changing conditions and work responsibilities.
- Display a positive attitude and is a positive agent for change.
- Ability to complete assigned tasks under stressful situations.
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Sixteenth Street Community Health Centers
Jul 09, 2026