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Community Care Manager

2 months ago

Annapolis, United States Luminis Health Full time

Community Care Manager (RN) - Maryland Primary Care Program (MDPCP)

Anne Arundel Medical Group, Department: Practice Solutions

Reports To: Clinical Director, Community Care Management

Full Time - Day shift (M-F)

FLSA Status: Non-Exempt/Hourly

Position Objective:

Endowed with clinical knowledge and experience, the Maryland Primary Care Program (MDPCP) Community Care Manager- RN works collaboratively with physicians, staff, and other health care professionals to provide care coordination and ensure that safety, best practices, and high quality standards are maintained across the continuum. S/he maintains knowledge of care management, behavioral health, and chronic disease self-management resources available to patients and facilitates patients' adoption of these services. S/he plays an integral role in promoting access to appropriate care, including transitional care services for vulnerable patients recently discharged from the hospital or ED, and providing care management to high-risk patients. S/he maintains access to and proficiency in programs including Epic, patient registries, and CRISP. Success will be measured by performance results at the practice and population levels.

Essential Job Duties:

  1. Assist patients through healthcare continuum as a patient advocate, navigator, and liaison to providers and/or community resources.
  2. Participate in team meetings and quality improvement initiatives, and provide feedback to staff to improve the care and referral processes.
  3. Facilitate health and disease patient education and support patient self-management of disease and behavior modification interventions.
  4. Coordinate continuity of patient care with providers across the healthcare system, including post-hospital or ED discharge.
  5. Use high-risk screening criteria to identify and manage high-risk patients, including patients with multiple comorbidities or at risk of readmission.
  6. Conduct comprehensive preventive screenings for patients.
  7. Facilitate patient medication management.
  8. Collaborate with patients, care team, and providers to understand patient short and long-term goals and set patient care plans.
  9. Participate on teams for data collection, health outcomes reporting, clinical audits, and programmatic evaluations related to the Maryland Primary Care Program (MDPCP).
  10. Evaluate clinical care, resource utilization, and development of new clinical tools, forms, and procedures.

Educational/Experience Requirements:

  • RN required, BSN preferred.
  • At least 5 years of experience in healthcare with care management experience.

Required License/Certifications:

  • RN license
  • CPR Certification (obtained within 6 months of start date)
  • Case Management Certification strongly preferred

Working Conditions, Equipment, Physical Demands:

There is a reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.

Physical Demands - Light Duty

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.