RN Care Mgr - Relocation Offered!

Baltimore, MD, United States

General Summary of Position

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 (Care Transformation Organization) interdisciplinary care team.

Primary Duties and Responsibilities

Under 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 Qualifications

Education Bachelor's degree in Nursing (BSN) required

Experience 3-4 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 Abilities Effective 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).

Why MedStar Health?

At MedStar Health, we understand that our ability to treat others well begins with how we treat each other. We work hard to foster an inclusive and positive environment where our associates feel valued, connected, and empowered. We live up to this promise through:

Strong emphasis on teamwork - our associates feel connected to each other and our mission as an organization. In return, our effective team environment generates positive patient outcomes and high associate satisfaction ratings that exceed the national benchmark.

Strategic focus on equity, inclusion, & diversity - we are committed to equity for all people and communities. We continue to build a diverse and inclusive workplace where people feel a sense of belonging and the ability to contribute to equitable care delivery and improved community health outcomes at all levels of the organization.

Comprehensive total rewards package - including competitive pay, generous paid time off, great health and wellness benefits, retirement savings, education assistance, and so much more.

More career opportunities closer to home - as the largest healthcare provider in the Baltimore-Washington, D.C. region, there are countless opportunities to grow your career and fulfill your aspirations.

About MedStar Health

MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It’s how we treat people.

MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations. MedStar Health makes all decisions regarding employment, including for example, hiring, transfer, promotion, compensation, benefit eligibility, discipline, and discharge without regard to any protected status, including race, color, creed, religion, national origin, citizenship status, sex, age, disability, veteran status, marital status, sexual orientation, gender identity or expression, political affiliations, or any other characteristic protected by federal, state or local EO laws. If you receive an offer of employment, it is MedStar Health's policy to hire its employees on an at-will basis, which means you or MedStar Health may terminate this relationship at any time, for any reason.