持牌实用护士-4

Job Description Summary
The LPN Care Team Member is responsible for conducting Chronic Care Management (CCM) outreach to patients with two or more chronic conditions. This role supports ongoing care coordination, improves patient outcomes, reduces avoidable hospitalizations and emergency department utilization, and promotes patient engagement through structured monthly outreach, education, care plan management and promotes patient well-being through timely follow-up, education, and coordination of services.Entity
MUSC Community Physicians (MCP)Worker Type
EmployeeWorker Sub-Type​
RegularCost Center
CC005802 MCP - Population Health Transitional Care Management (TCM)Pay Rate Type
HourlyPay Grade
Health-25Scheduled Weekly Hours
40Work Shift
Job Description

Chronic Care Management (CCM)

Key Responsibilities
• Conduct monthly telephonic outreach to assigned CCM patient panel
• Complete a minimum of 20 minutes of non–face-to-face care management services per patient per calendar month
• Perform at least two outreach attempts for patients not reached
• Assess patient status, including changes in condition, symptoms, or care needs
• Review and reinforce individualized care plans and patient goals
• Support medication adherence and identify potential medication concerns
• Identify and address barriers to care (e.g., transportation, access to medications, social needs)
• Assist with scheduling appointments when clinical evaluation is needed
• Escalate clinical concerns to appropriate clinical support staff or providers per workflow standards
• Document all interactions accurately in the electronic health record (EHR) and track time for billing compliance
• Collaborate with providers, care teams, and community resources to ensure continuity of care
Care Coordination & Patient Engagement
• Provide education on chronic disease management and preventive care
• Encourage patient participation in primary care and adherence to treatment plans
• Monitor for signs of deterioration and escalate concerns appropriately
• Support transitions of care when applicable
• Promote patient self-management and engagement in their health
Required Skills & Competencies
• Strong communication and interpersonal skills
• Ability to assess patient needs and apply clinical judgment appropriately
• Proficiency in EHR documentation and care coordination workflows (experience with Epic Systems preferred)
• Knowledge of chronic disease management and population health principles
• Ability to manage a high-volume patient panel efficiently
• Strong organizational and time management skills
• Ability to work independently within established workflows and SOPs
• Ability to appropriately route communication to providers vs. clinical support teams
Qualifications
• Active LPN licensure in good standing (South Carolina preferred)
• BLS (Basic Life Support) certification (if required by role)
• Prior experience in care coordination, case management, ambulatory care, or chronic disease management preferred
• Experience working with high-risk or chronic condition populations strongly preferred
Additional Job Description

Benefits:

• Health, dental, vision, and life insurance

• Employer Sponsored Retirement Plan

• Paid time off and extended sick leave

• Paid Parental Leave

• Disability insurance plan options

• Continuous professional and clinical training

• Competitive pay

• Annual Merit Increase

• Wellbeing resources

• Tuition Reimbursement

• Employee perks and discounts

• Employee referral program

• Flexible schedule options

• Certification incentive program

If you like working with energetic enthusiastic individuals, you will enjoy your career with us!
The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.
Medical University of South Carolina participates in the federal E-Verify program to confirm the identity and employment authorization of all newly hired employees. For further information about the E-Verify program, please click here:
Originally posted on Himalayas