General Summary of PositionResponsible for the care management and care coordination of Medicare beneficiaries attributed to a medical practice(s). Serves as the liaison between the medical practice and the CTO's (Care Transformation Organization) interdisciplinary care team.
Primary Duties and ResponsibilitiesUnder the direction of the practicing physician, perform direct patient care including wellness visits, transitional care; administer vaccinations, screenings, etc.Assesses, plans, implements, monitors and evaluates options and services to meet the health needs of attributed beneficiaries. Manages a caseload in compliance with contractual obligations and the MD Primary Care Program (MDPCP) standards.Conducts comprehensive member assessments through root cause analysis based on members' needs and performs clinical intervention through the development of a care management treatment plan specific to each member with high level acuity needs.Monitors and evaluates the effectiveness of the care plan and modifies the plan as needed. Supports member access to appropriate quality and cost-effective care. Coordinates with internal and external resources to meet identified needs of the member's care plan and collaborates with providers.Acts as a liaison and member advocate between the member/family, physician, and facilities/agencies. Provides clinical consultation to physicians, professional staff, and other teams members/supervisors to provide optimal quality patient care and effective operations.Interacts continuously with members, family, physician(s), and other resources to determine appropriate behavioral action needed to address medical needs. Reviews benefits options, researches community resources, trains/creates behavioral routines, and enables members to be active participants in their own healthcare.Ensures members are engaging with their PCP to complete their care management treatment plan or preventive care services.In collaboration with the interdisciplinary care team, acts as primary care team agent for the coordination of care for a panel of attributed Medicare beneficiaries by ensuring the following: Attributed beneficiaries have timely access to care (same day or next-day access to the patient's own practitioner and/or care team for urgent care or transition management).Support and facilitate alternatives for care outside of the traditional office visit to increase access to the care team and the practitioner, such as e-visits, phone visits, group visits, home visits, and visits in alternate locations (senior centers, assisted living) captured in the medical record. Assist patients with scheduling appointments with providers including annual wellness visits. Attributed beneficiaries receive a follow-up interaction from the practice within 2 days for hospital discharge and within one week for Emergency Department (ED) discharges.Coordinates referral management for attributed beneficiaries seeking care from high-volume and/or high-cost specialists as well as EDs and hospitals. Facilitate connection to services for patients who may benefit from behavioral health services, including patients with serious mental illness; patients with substance use disorders' patients with depression, anxiety, or other mental health conditions; patients with behavioral and social risk factors and BH issues; patients with multiple co-morbidities and BH issues.Assist with identifying patients to participate in the Patient-Family/ Caregiver Advisory Council (PFAC) and help to organize and facilitate the PFAC annual meetings. Engage attributed beneficiaries and caregivers in a collaborative process for advance care planning (MOLST, Advanced Directives, Proxy).Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards. Complies with governmental and accreditation regulations.Daily telephonic patient communication to help to close gaps in care and provide up-to-date healthcare information helping to facilitate the member's understanding of his/her health status using available reports including quality m page and HIE CRISP to ensure relevant medical history/encounter are accessible in EMR.Facilitates ongoing communication amongst practice and care team by participating in huddles, hosting regular conference calls, in-person meetings, or coordinating regular email updates to ensure alignment of activity, discuss new developments, and exchange information.Perform analysis of attributed beneficiary data and presents data intelligently and creatively in a way that can be easily and quickly grasped by the practice and interdisciplinary care team as appropriate.Participates and supports multidisciplinary quality initiatives to close care gaps and service improvement teams as appropriate. Participates in meetings including: regular staff meetings, training classes for safety, infection control, OSHA, EMR, CPR, TJC, safety, compliance, and others as required; Serves on committees and represents the department and facility in community outreach efforts as appropriate.
Minimum QualificationsEducationBachelor's degree in Nursing (BSN) required
Experience3-4 years Work experience. Familiarity with the local area and/or population health workforce integration required and Experience with data collection and reporting and community outreach experience. Experience working in an ambulatory setting preferred
Licenses and Certifications Registered Nurse licensed in Maryland required Certified Case Manager (CCM) from a nationally recognized certification agency preferred or CCM certification within 1 Year preferred
Knowledge, Skills, and AbilitiesEffective verbal and written communication skills.Excellent interpersonal and customer service skills especially serving geriatric patients.Strong analytical and critical thinking skills.Strong community engagement and facilitation skills.Advanced project management skills.Commitment to collective impact concepts.Flexibility and the ability to work autonomously as well as take direction as needed.Cultural competency.Proficient computer skills along with experience using Microsoft applications-Word, Excel, etc. and familiarity with entering data in an electronic medical record (EMR).
This position has a hiring range of $87,318 - $157,289