Supports, and is responsible for incorporating into job performance, the Frederick Health (FH) mission, vision, core values and customer service philosophy and adheres to the FH Compliance Program, including following all regulatory requirements and the FH Standards of Behavior. The Integrated Care Management- Care Manager RN will work collaboratively with physicians, staff, and other healthcare professionals within ambulatory Frederick Health Medical Group practices and/or community practices that participate in the clinically integrated network (CIN)- Frederick Integrated Healthcare Network (FIHN). Care coordination will focus on requirements of various value-based care contracts and population health focus areas. Transitions of care, risk stratification data, and provider/care team referrals will initiate care management within this population. The Care Manager RN will interpret data to evaluate and implement care management strategies and interventions related to attributed beneficiaries and patient populations. Optimizes patient wellness through the promotion of self-management strategies. Telephonic, medical office, and home visits will be conducted. Example of Essential Functions: Delivery of care coordination within Frederick Health which may include hospital or ambulatory site assignment. Performs individualized assessments and planning to develop the plan of care to address identified needs. Identification of barriers to care including but not limited to disease education needs, socioeconomic status, unmet social needs, impaired coping, support network dysfunction. Promotes and values diversity to promote inclusive working relationships. Communication with interdisciplinary care team, patients, and families Promotes coordination with healthcare professionals. Monitors and evaluates care management plans. Provides education regarding condition and symptom management. Possesses working knowledge of regulatory components of assigned healthcare setting.
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Job Type
Full-time
Career Level
Mid Level
Number of Employees
501-1,000 employees