• Develop, implement, and monitor individualized care plans for patients with chronic conditions such as diabetes, hypertension, heart disease, COPD, and others.
• Conduct regular telephonic or in-person follow-ups with patients to assess health status, adherence to care plans, and address any barriers to care.
• Collaborate with primary care providers and specialists to ensure continuity and coordination of care.
• Educate patients and caregivers on disease management, medications, nutrition, and lifestyle modifications.
• Assist patients in navigating the healthcare system and accessing appropriate community resources.
• Track and document patient interactions and outcomes in the electronic health record (EHR).
• Monitor and report patient metrics and quality improvement data (e.g., HEDIS, CMS requirements).
• Participate in interdisciplinary team meetings to discuss patient progress and update care strategies.
• Identify high-risk patients using risk stratification tools and proactively engage them in care management.
• Ensure compliance with Medicare Chronic Care Management (CCM) billing requirements, when applicable.

Job Types: Full-time, Contract

Pay: $33.00 - $38.00 per hour

Expected hours: 37.5 per week

Benefits:

• Life insurance

Education:

• Bachelor's (Required)

Experience:

• Chronic pain counseling: 3 years (Preferred)

Ability to Commute:

• Nashville, TN 37243 (Required)

Ability to Relocate:

• Nashville, TN 37243: Relocate before starting work (Required)

Willingness to travel:

• 25% (Preferred)

Work Location: In person