General Summary of PositionServes as a member of the interdisciplinary care management team capable of furnishing an array of care coordination services to Medicare FFS beneficiaries attributed to practices that the Care Transformation Organization (CTO) supports. Responsible 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 interdisciplinary care team.
Primary Duties and ResponsibilitiesContributes 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.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: Ensures 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); Facilitates use of 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; Assists 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; Facilitates 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; Assists with identifying patients to participate in the Patient-Family/ Caregiver Advisory Council (PFAC) and help to organize and facilitate the PFAC annual meetings; Engages attributed beneficiaries and caregivers in a collaborative process for advance care planning (MOLST, Advanced Directives, Proxy).Under the direction of the practice physician, may perform direct patient care including wellness visits, transitional care, administer vaccinations, screenings, etc.Assesses, plans, implements, monitors and evaluates options and services to meet 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 member's 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 effectiveness of care plan and modifies 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.Ensures daily telephonic patient communication to help to close gaps in care and provide up-to-date healthcare information helping to facilitate the members 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.Performs 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 in multidisciplinary quality and service improvement teams as appropriate. Participates in meetings, serves on committees and represents the department and hospital/facility in community outreach efforts as appropriate.Performs other duties as assigned.
Minimum QualificationsEducationAssociate's degree in Nursing (ADN) required andBachelor's degree in Nursing (BSN) preferred
Experience3-4 years Work experience including 1 or more years of proven case management experience. Familiarity with the local area and/or population health workforce integration. required and Experience with data collection and reporting; community outreach experience,experience working in an ambulatory setting preferred
Licenses and CertificationsRN - Registered Nurse - State Licensure and/or Compact State Licensure Registered Nurse licensed in the State of Maryland Upon Hire required andCCM - Certified Case Manager from a nationally recognized certification agency within 1-1/2 Yrs preferred andDL NUMBER - Driver License, Valid and in State (DRLIC) Upon Hire required
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