[Self-Management_OR] chronic disease management job announcement

Chisholm Laura F LAURA.F.CHISHOLM at dhsoha.state.or.us
Thu Jan 5 13:57:21 PST 2017

Hi friends,
I'm passing this information along to the listserv on behalf of a former a colleague, Dr. Brian Martin. Please address any inquiries about the position to him directly at brian.martin at recentiahealth.com<mailto:brian.martin at recentiahealth.com>.




* Contribute towards the success of Recentia's customers and investors.

* Design, implement and execute an outsourced Medicare Care Coordination Management program on behalf of primary care physicians for a Patient Cohort defined by Medicare Beneficiaries enrolled in the Medicare Fee-For-Service Program (also known as Original Medicare) who are 65 year of age or older and who have two or more chronic conditions that are expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

* Work with each patient's primary care physician to establish, implement, monitor, and revise a comprehensive care management plan that adheres to Medicare's Clinical Quality Measures.

* Provide at least 20 minutes per calendar month of non-face-to-face clinical staff time, under the direction of a physician or other qualified health care professional, to each patient in the patient cohort as defined above.

* Manage care transitions between and among health care providers and settings, including referrals to other providers, including providing follow-up: o after an emergency department visit; and

o after discharges from hospitals, skilled nursing facilities, or other health care facilities.

* Coordinate care with home- and community-based clinical service providers.

* Work with the patient's primary care physician to bill for services under CPT code 99490.

* Ensure that all requirements for reimbursement for services under CPT Code 99490 are met on a monthly basis for each patient.

* Care management services may include: o -Systematic assessment of the patient's medical, functional, and psychosocial needs;

o -System-based approaches to ensure timely receipt of all recommended preventive care services;

o -Medication reconciliation with review of adherence and potential interactions; and

o -Oversight of patient self-management of medications.


* Excellent understanding of current research findings in health education and promotion and chronic disease management.

* Skilled at linking applied research to practice.

* Understand how to apply proven peer-reviewed methods for chronic disease management to practice.

* Excellent patient recruitment and engagement skills.

* Commitment to excellence.

* Commitment to intellectual and personal integrity.

* Commitment to design without compromise.

* Excellent critical thinking and problem solving skills.

* Excellent verbal and written communication skills.

* Excellent presentation and public speaking skills.

* Vision-the ability to think big and clearly articulate Recentia's vision to different audiences, e.g., patients, consumers, physicians, business executives and investors.

* Ability to write effective and concise copy.

* Ability to repetitively drive execution of incremental short-term strategies.

* Ability to understand disruptive opportunities and effectively communicate these opportunities to Recentia's team.

* Ability to differentiate between good design and exceptional design.

* Ability to assess the effort and likelihood of success across teams.

* Ability to understand the various operating teams, how they work, and the interplay between motivations, processes, mindsets, communication styles, skill sets and corporate culture.


* Experience designing and implementing chronic disease management programs.


* MPH or DrPH in health education and promotion from an accredited school of public health; or

* MSW in clinical social work from an accredited school of social work.

Laura F. Chisholm, MPH, MA, MCHES
Injury Prevention Program Manager
Injury & Violence Prevention Program

Desk: 971-673-0987
Mobile: 503-841-4842
Laura.f.chisholm at state.or.us<mailto:Laura.f.chisholm at state.or.us>


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