Millennium Physician Group
  • 08-Jan-2019 to 09-Mar-2020 (EST)
  • Naples, FL, USA
  • Salary
  • Full Time

The ACO Chronic Care Management (CCM) Field Case Manager is responsible for assessing, planning, intervening and evaluating outcomes for patients participating in the Millennium Chronic Care Management Program. Working closely with the telephonic case manager, clinical support staff, nursing leadership and physicians, the CCC Field Case Manager is tasked with achieving program goals of improving clinical outcome for patients with chronic diseases using timely and appropriate coordination of quality healthcare services to meet an individual's specific health needs to promote positive outcomes. The CCC Field Case Manager collaborates with patients, families, caregivers, primary care physicians and specialists to develop, implement and modify the plan of care for individuals with chronic diseases based on an in-depth assessment and interventions which support national standards for care and the disease management process.

Job Standards:

  • Provides chronic care management to patients in the Chronic Care Management Program with multiple co-morbidities, or those with certain chronic conditions, including, but not limited to, diabetes, cardiovascular disease, and COPD. This is primarily a field based function, but will also include some selected office visits with patients.
  • Demonstrates experience working with geriatric patient population preferred with training in chronic disease management with a focus on conditions of HF, Diabetes, COPD.
  • Demonstrates knowledge of evidence based clinical practice guidelines particularly for chronic conditions.
  • Independently assesses, evaluates and interprets clinical information and care planning.
  • Utilizes Millennium Athena system and Patient registries effectively to accurately document patient assessment and develop timely care plans for the telephonic case management team.
  • RN license is required


Millennium Physician Group
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