Chronic Disease Coordinator [Clerical Staff] Job Description

To assist Doctors, Practice Nurse and patients in the effective management of chronic
disease care.

Provide efficient service directly relating to patient recall and follow-up
appointments.

Liaison with Doctors and Practice Nurse on matters pertaining to chronic disease and those patients within the Practice & community to level of training.

Effectively use the computer programs necessary to obtain the data needed to
perform duties.

Monitor and ensure appropriate claiming of GPMP, TCA and SIP payments.

Duties & Responsibilities:

■Manage the Practice Nurse’s workload/appointments; keeping 1 week ahead of him/her
using the recall system and Doctors direction.

■Monitor the chronic heart disease, diabetes pts,75, 45-49 and 4 year old patients, Pap smear recalls, immunization catch-up program using Best Practice search function, recall system and Penn Cat Clinical Audit program.

■New 75 yo health assessments: phone these patients to offer and explain the assessment process and then arrange appointments for the Practice Nurse to visit them at home or see in the clinic. Monitor patients to ensure follow up appointments with the Doctor are
carried out.

Annual health checks on all 75 yo patients organise weekly.

■45-49 health assessments and 4 yo Healthy Kids Check : letters of invitation and
subsequent monitoring every 6 months.

■Extract data monthly: examine reports and evaluate clinical results for improvements or decline. In consultation with Doctors & Practice Nurse, recall patients for further
monitoring/tests.

■Immunisation catch-up program: letter sent explaining the program and invitation offered to eligible patients .

■Pap smear results,: notification of results and recommended repeat smear test letters.
Recalls added to patients file.

■Practice Nurse Flu Clinics : arrange at appropriate times of the year [usually April/May].

■Liaison with Doctors discussing overdue tests, immunizations and pap smears. Give
Doctors a list of “jobs” to do weekly to assist Practice Nurse which usually involves ‘tiding up” patient files and printing path forms.

■Monitor Medicare claims of those pts with GPMP’s, TCA’s, reviews and SIP payments.

Raelene

Mary’s tracking sheets have been uploaded to this page (click)

We love this idea. Does anyone have a Job Description that we could use as a basis for developing ours?

thanks, Trish