Community Care Manager (RN) - MDPCP

Luminis Health • Annapolis, MD

5d • $39 - $58 • Onsite

About The Position

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.

Requirements

• RN required, BSN preferred.
• At least 5 years of experience in healthcare with care management experience.
• RN license
• CPR Certification (obtained within 6 months of start date)

Nice To Haves

• Case Management Certification strongly preferred

Responsibilities

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

Benefits

• Medical, Dental, and Vision Insurance.
• Retirement Plan w/employer contribution.
• Paid Time Off.
• Employee Tuition Assistance Benefits.
• Employee Referral Bonus Program
• Employer Paid Holidays, Disability, and Life/AD&D for full time employees
• Wellness Programs/Employee Assistance Programs and more

What This Job Offers

• Job Type: Full-time
• Career Level: Senior