Community Care Manager (RN) - MDPCP

<p>&nbsp;</p><p><strong>Position Objective:</strong></p><p>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.</p><p><strong>Essential Job Duties:</strong></p><ol><li>Assist patients through healthcare continuum as a patient advocate, navigator, and liaison to providers and/or community resources.</li><li>Participate in team meetings and quality improvement initiatives, and provide feedback to staff to improve the care and referral processes.</li><li>Facilitate health and disease patient education and support patient self-management of disease and behavior modification interventions.</li><li>Coordinate continuity of patient care with providers across the healthcare system, including post-hospital or ED discharge.</li><li>Use high-risk screening criteria to identify and manage high-risk patients, including patients with multiple comorbidities or at risk of readmission.</li><li>Conduct comprehensive preventive screenings for patients.</li><li>Facilitate patient medication management.</li><li>Collaborate with patients, care team, and providers to understand patient short and long-term goals and set patient care plans.</li><li>Participate on teams for data collection, health outcomes reporting, clinical audits, and programmatic evaluations related to the Maryland Primary Care Program (MDPCP).</li><li>Evaluate clinical care, resource utilization, and development of new clinical tools, forms, and procedures.</li></ol><p><strong>Educational/Experience Requirements:</strong></p><ul><li>RN required, BSN preferred.</li><li>At least 5 years of experience in healthcare with care management experience.</li></ul><p><strong>Required License/Certifications:</strong></p><ul><li>RN license</li><li>CPR Certification (obtained within 6 months of start date)</li><li>Case Management