Chronic Care Manager/Certified Application Counselor (RN)

Job Description:

Chronic Care Manager / Certified Application Counselor (RN)

Position Summary

The Chronic Care Manager / Certified Application Counselor (RN) provides comprehensive patient support services for St. George Medical Clinic (SGMC) through chronic care coordination and health insurance enrollment assistance. This position supports providers by managing chronic disease patient populations, developing individualized care plans, coordinating follow-up care, and assisting patients in accessing healthcare coverage and community resources.

The role combines clinical care management with Affordable Care Act (ACA) enrollment assistance to improve access to care, enhance patient compliance, reduce avoidable hospital utilization, and support population health initiatives.

Services are delivered through in-person and/or telephonic encounters while maintaining strict patient confidentiality and compliance with all federal, state, and organizational regulations.

Essential Functions

Chronic Care Management Responsibilities

• Develop positive, professional interactions with patients on behalf of SGMC providers.


• Conduct in-person and/or telephonic chronic care management encounters.


• Develop and maintain individualized patient care plans for prevention, intervention, and chronic disease management.


• Collect, review, and analyze patient health information in accordance with clinic protocols.


• Communicate relevant patient data and care concerns to providers for clinical decision-making.


• Track emergency room visits, hospital admissions, and coordinate post-discharge follow-up care.


• Implement outreach efforts to promote patient compliance, engagement, and access to care.


• Coordinate care with physicians, nursing staff, and interdisciplinary team members.


• Identify and utilize appropriate community resources to address patient needs.


• Support ongoing care management, monitoring, and follow-up activities.


• Participate in data collection and reporting for Quality Assurance/Quality Improvement (QA/QI) initiatives.


• Follow established provider orders and approved plans of care.


• Refrain from initiating independent treatment plans, including over-the-counter medications or exercise programs, unless prescribed or authorized by a provider.

Certified Application Counselor (CAC) Responsibilities

• Complete and maintain all required state CAC training, certification, and continuing education requirements.


• Provide free, impartial, and confidential assistance to patients seeking health insurance coverage.


• Educate consumers on healthcare coverage options, including:
  
  
  
  • ACA Marketplace plans/Medicare
  
  
  • Medicaid
  
  
  • Children’s Health Insurance Program (CHIP)
  
  
  • Veteran Programs
  
  
  • Qualified Health Plans (QHPs)
  
  
  • Advanced Premium Tax Credits (APTC)
  
  
  • Cost-Sharing Reductions (CSR)
  
  
  
  


• Assist patients with eligibility determination and enrollment applications.


• Conduct outreach and education activities within targeted communities regarding available health coverage programs.


• Travel between SGMC locations as required to provide enrollment assistance.


• Maintain strict confidentiality when handling sensitive personal and financial information.


• Document enrollment activities according to regulatory and organizational requirements.

Competencies Required

• Active Registered Nurse (RN) license in the State of West Virginia.


• Knowledge of chronic disease management and population health principles.


• Understanding of healthcare access programs and insurance enrollment processes.


• Ability to provide prevention and intervention support through motivational coaching techniques.


• Proficiency with Electronic Health Records (EHR) systems.


• Strong organizational, analytical, and documentation skills.


• Excellent interpersonal, communication, and patient education abilities.


• Ability to work both independently and collaboratively within a healthcare team.


• High attention to detail and commitment to patient confidentiality.

Position Type and Expected Hours of Work

• Full-time position.


• The RN will be assigned a patient panel based on skill level and efficiency.


• Expected to manage a minimum of 120+ patients per calendar month.


• Average patient encounter duration: approximately 20 minutes.


• Expected completion rate: 90% of assigned patient encounters monthly.


• May require travel between SGMC service locations.

Work Environment

Work is performed primarily in an environmentally controlled clinical or office setting. The position requires frequent interaction with patients, providers, staff, insurance representatives, and members of the public.

Appropriate safety protocols and infection control procedures must be followed at all times.

Qualifications

• Current, active West Virginia Registered Nurse license.


• CAC certification (or ability to obtain within required timeframe).


• Proficiency in Microsoft Office applications (Word, Excel, PowerPoint).


• Comfortable using web-based systems and database software.


• Excellent organizational and time-management skills.


• Demonstrated ability to maintain professionalism and confidentiality.


• Ability to work effectively in both independent and team-based settings.