MDPCP Care Coordinator

Privia Health•Frederick, MD

10d•$51,000 - $63,000

About The Position

This role requires candidates to be located in the DMV (D.C., Maryland, Virginia) area. The Maryland Primary Care Program (MDPCP) Care Coordinator will work closely with Primary Care providers in the state of Maryland to identify, screen, track, monitor, and coordinate the care of patients with multiple chronic conditions to develop and deliver Comprehensive Primary Care to patients. Our Care Coordinators seek to develop, implement, and deliver extensive care coordination within our medical group and affiliated partners in a patient centered manner. They interact and collaborate with interdisciplinary care teams, population health teams, networked facility partners, physicians, and others involved in meeting the patient’s needs.

Requirements

Clear understanding of MDPCP program, mission, vision and goal
Strong computer and EHR skills and expertise
Experience working in an outpatient medical office
Ability to travel to and from care centers to meet with patients and providers
Must comply with all HIPAA rules and regulations

Nice To Haves

Preferred experience with Medicare aged patients in a value-based program
Preferred experience educating and engaging patients

Responsibilities

Collaborate with assigned local teams to meet Maryland Primary Care Program performance metrics
Own the execution and performance toward defined performance metrics
Collaborate effectively with integrated care team to support care coordination for patients
Review patient non-compliance reports and conduct telephonic and/or in person outreach to ensure timely disease specific and wellness visits
Independently conduct Annual Wellness Visits as needed
Provide Transitional Care Management including, but not limited to, post in-patient and/or emergency department discharge follow up
Provide education and assistance in accessing the necessary care outside of the Primary Care Office
Collaborate with providers to review high-risk patients, develop a plan of care, and administer Care Plan to patients
As needed, meet patients in the office or community for face-to-face visits
Provide education and assistance with patient self-management goals
Identify and coordinate referrals to community resources, home care, and disease management programs within Privia Preferred Network
Operate independently within defined practice(s) and patient population to achieve agreed upon goals
Attendance and participation in regular care team meetings to discuss patient care
Perform other duties as assigned