Care Management Nurse

Kolmac Clinic•Cumberland, MD

12h•$35 - $38•Hybrid

About The Position

We are currently in search of an experienced Care Management Nurse (Health Home) for our Cumberland, MD location working a hybrid schedule. The Care Management Nurse at Kolmac Integrated Behavioral Health oversees the implementation of the CCG Population Health. This position is accountable for designing and maintaining systems to ensure the continuity of care between the OTP program and somatic and behavioral healthcare providers both within CCG and in the community, as well as developing processes to assist consumers in the development and maintenance of healthy lifestyles and illness management skills.

Requirements

Must has a valid driver’s license with no more than 3 points
Three plus years’ experience in a medical office setting, hospital, or similar patient customer service environment.
Licensure as a Registered Nurse in the state of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, is
Demonstrated success in exhibiting teaching, coaching, and development skills
Demonstrated effectiveness in a consultative role, and experience leading complex change
Ability to create a motivating environment for clinical and professional personnel
Highly effective interpersonal, verbal, and written communication and presentation skills.
The successful
Demonstrate effectiveness in education others on a broad spectrum of health issues
Demonstrate ability to collaborate with a multidisciplinary treatment team
Strong sense of teamwork and collaboration, as caseload coverage is shared amongst the entire Population Health Nurse Care team and all aspects of services are further coordinated with several multi-disciplinary teams
Technically proficient in Microsoft Office programs and database use.
Ability to learn and use an electronic medical record and health information exchange to enter clinical information and run reports

Nice To Haves

Five plus years, preferred
Knowledge of the Maryland healthcare industry and policy preferred
Ability to conduct online research to source information and resources for clients preferred
Knowledge of area resources and case management preferred

Responsibilities

Acts as a comprehensive care coordinator for participants assigned to care, assessing their needs accordingly and facilitating communication amongst other clinicians providing care
Leads practice transformation based on Population Health principles and state/accrediting body requirements
With agency leadership, acts as a "champion" for the Population Health philosophy and provides education to staff
Develops and maintains working relationships with primary and specialty care providers including inpatient facilities and emergency departments
Monitors Population Health performance at the population and participant level and implements improvement efforts via statistical data gathering
Designs and develops prevention and wellness initiatives
Establishes the effective use of patient registries (CRISP and eMedicaid ) as applicable to manage specific patient populations and to improve disease and population health outcome measures
Collaborates/consults with specialty practices to identify data needs related to care coordination
Monitors participants' monthly visits to assure the appropriate population home are delivered
Oversees the entering of all required data
Performs comprehensive assessments of physical, emotional, psychosocial and environmental needs of participants and develop care plans for all assigned Population Health enrollees around physical health or social goals
Facilitates health education groups
Assesses, coordinates and implements service planning needs of assigned persons
Evaluates/assists in evaluation of appropriateness of plan of care and revises on an ongoing basis with communication to all other disciplines
Reviews result of laboratory tests and other diagnostic procedures and reports to the nurse practitioner or psychiatrist
Identifies significant clinical findings, makes conclusions and intervenes appropriately under the direction of the nurse practitioner consultant
Compares ongoing outcome data to baseline data to monitor clients
Initiates client education based on identified learning needs of the client and/or those providing care and documents appropriately
Supports and monitors compliance of the individual including checking of prescription labels and storage
Consults with behavioral health staff about participants identified health conditions
Attends treatment team meetings with behavioral health staff to plan and coordinate care
Assists in contacting medical providers & hospitals for coordination of care efforts
Supports medical and nursing team with admissions
Provides training on medical diseases, treatments, & medications to health home participants
Assists in the training and education of OTP staff regarding population health services
Provides training on medical diseases, treatments, & medications to behavioral health staff, as indicated
Takes action to correct observed risks to patient safety
Reports adverse events and near misses to supervisor
Develops effective working relationships and maintains good communication with other team members.
Identifies possible risks in processes, procedures, devices and communicates the same to those in charge
Provides dispensing coverage and other needed dispensing / med room tasks as needed. This may be recurring scheduled dispensing coverage, as backup coverage for dispensing nurses, or for emergency coverage
Other duties as assigned

Benefits

Affordable Health, Dental & Vision Insurance
Comprehensive coverage with low employee costs, generous employer contributions, minimal deductibles, and multiple plan options to support you and your family.
Generous Paid Time Off
We prioritize work-life balance with a generous PTO accrual, paid professional development days, and 7 company-paid holidays each year.
401(k) Retirement Savings Plan
Plan ahead with flexible 401(k) options, including both traditional and Roth contributions, to help you build a secure financial future.
Company-Paid Life & Disability Coverage
Gain peace of mind with fully paid life insurance, accidental death & dismemberment (AD&D), and short-term disability benefits.
Tuition Reimbursement & Student Loan Assistance
Advance your education with tuition reimbursement and ease the burden of student debt with support for loan repayment for qualifying staff.