Healthcare Coordinator

4 weeks ago


Baltimore, Maryland, United States Chase Brexton Health Care Full time
Job Summary

The Care Management Specialist delivers and oversees care management services for medically and/or socioeconomically complex patients in accordance with patient-defined goals, multi-disciplinary plan of care, and established policies and procedures.

Drawing on best practices in motivational interviewing and care management, the Care Management Specialist collaborates with clients and multi-disciplinary teams to develop and implement flexible, patient-centered, and cost-effective strategies that support clients to achieve health-related goals.

The Care Management Specialist will collect and analyze patient-level data, assist with development and maintenance of care plans, and evaluate outcomes of interventions.

The Care Management Specialist also serves as a role model and mentor to staff on best practices in care coordination, motivational interviewing, and addressing social determinants of health.

Assures compliance with regulatory body standards (including Joint Commission, HRSA, PCMH, and grant funding sources).

Key Responsibilities
  • Develop systems and processes to engage patients in self-management and care navigation.
  • Ensure that appropriate community resources, home care, and ancillary services are in place and being delivered.
  • Identify high and rising-risk, high-need, and potentially high-cost patients within the assigned panel of Chase Brexton Health Care patients.
  • Identify patients at risk for poor outcomes and those who may require more intensive services; provide additional outreach and frequent follow-up (by phone and in-person) to this population.
  • Provide complex case management, including chronic disease case management, care coordination, transition care management, high-risk clinical tracking, and complex medication management to appropriate patients.
  • Access appropriate resources inside and outside the organization to meet the needs of the patient.
  • Provide referrals to appropriate community resources; facilitate access and communication when multiple services are involved; monitor activities to ensure that services are actually being delivered and meet the needs of the patient, coordinate services to avoid duplication.
Requirements
  • Graduate from an Accredited School of Nursing; Current Maryland Nursing License.
  • At least five years of related nursing experience serving vulnerable clients in a community-based, home-based, or ambulatory care setting.
  • Chronic disease management experience.
  • Encouraged to maintain membership in professional organizations such as the AAACN, ANAC, etc.
  • Preferred: Case Management Certification.


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