Position Summary

A Population Health Case Manager (aka Health Nurse) at Alterwood Health are compassionate and resourceful in bringing positive change to members’ health. Health Nurses are responsible for delivering Alterwood Health’s Model of Care (MOC), one member at time, through assessing their healthcare needs, ensuring members have the tools to manage their health, and motivating/guiding members to seek appropriate care in a complex healthcare system. Through these interactions with members, their caregivers, and their providers, the Health Nurse will close gaps in care while advocating members’ and providers’ satisfaction with the plan.

Essential Duties and Responsibilities

• Ensure the Health Risk Assessment (HRA) is completed by members and coordinate with Health Coordinators on members who have not completed the HRA.
• Assess members’ access to needed medical, psychiatric, pharmaceuticals, social, educational, and other services essential to meet the healthcare needs of members; and determine if there are any barrier(s) to members’ healthcare needs.
• Educate and counsels members and their family members, including AORs, on how best to manage health conditions/disease/injury processes, assist them to identify and resolve barriers to accessing care, find ways for members to adjust to changes in physical capabilities, and motivate/guide members in optimizing their health and well-being.
• Develop an Individualized Care Plan (ICP) based on HRA and member assessment(s).
• Collaborates with Interdisciplinary Care Team (ICT) to ensure a cross-functional feedback on members’ care.
• Provides support for transitional of care activities and promotes continuity of care for members’ safe admissions, transfers, and discharges from hospital to skilled nursing and/or to home.
• Helps decrease re-hospitalizations by providing education to members on preventative measures to improve outcomes.
• Maintains collaborative working relationships with members’ providers, the appropriate state agencies, delegated vendors, and community providers.
• May perform duties telephonically as well as conducting on-site visits
• Prepares, completes, and maintains clinical documentation in clinical systems through written case records/notes, ICPs, and performs case follow-up and closer, and performs other administrative tasks as required and in accordance with best practices and Medicare/Federal guidelines.
• Oversees and supervises health coordinators and other non-clinical staff in accordance with the MOC.
• Perform any other job-related instructions, as requested.

Education, Experience and Qualifications

• Bachelor’s degree in nursing or social work
• Licensed as a registered nurse or social worker with the applicable state board license.
• At least two (2) years of clinical practice experience as a nurse or social working in a hospital or outpatient setting. Med/surg preferred.
• At least one (1) year experience as a Case Manager or Coordinator at a health plan or healthcare setting.
• A working knowledge of Medicare program requirements.
• Current Certified Case Manager (CCM) or similar certification preferred.

Knowledge, Skills and Abilities

• Excellent communication skills, including writing, critical-thinking, and the ability to work with others in a collaborative fashion.
• Ability to assess patients’ clinical needs and barriers to optimal health plus create a personalized care plan that can be understood and followed by members and/or their caregiver(s).
• Working knowledge of health insurance and the clinical activities supporting members.

Physical Requirements

• Please see Exhibit A

Computer Skills

• Good computer skills (demonstrated use of Microsoft products, including Outlook, Excel, Word, and latest web-browsers) and overall computer use literacy.

Affirmative Action/EEO statement

The Company provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

Other duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Exhibit A

Checklist: Job Analysis/Job Description Physical Activities

Physical Activities

Ascending or descending ladders, stairs, scaffolding, ramps, poles and the like.
☒ Never ☐ Occasionally ☐ Constantly

Moving self in different positions to accomplish tasks in various environments including tight and confined spaces.
☒ Never ☐ Occasionally ☐ Constantly

Remaining in a stationary position, often standing or sitting for prolonged periods.
☐ Never ☐ Occasionally ☒ Constantly

Moving about to accomplish tasks or moving from one worksite to another.
☒ Never ☐ Occasionally ☐ Constantly

Adjusting or moving objects up to 15 pounds in all directions.
☐ Never ☒ Occasionally ☐ Constantly

Communicating with others to exchange information.
☐ Never ☐ Occasionally ☒ Constantly

Repeating motions that may include the wrists, hands and/or fingers.
☐ Never ☐ Occasionally ☒ Constantly

Operating machinery and/or power tools.
☒ Never ☐ Occasionally ☐ Constantly

Operating motor vehicles or heavy equipment.
☒ Never ☐ Occasionally ☐ Constantly

Assessing the accuracy, neatness and thoroughness of the work assigned.
☐ Never ☐ Occasionally ☒ Constantly

Environmental Conditions

Low temperatures.
☒ Never ☐ Occasionally ☐ Constantly

High temperatures.
☒ Never ☐ Occasionally ☐ Constantly

Outdoor elements such as precipitation and wind.
☒ Never ☐ Occasionally ☐ Constantly

Noisy environments.
☐ Never ☒ Occasionally ☐ Constantly

Hazardous conditions.
☒ Never ☐ Occasionally ☐ Constantly

Poor ventilation.
☒ Never ☐ Occasionally ☐ Constantly

Small and/or enclosed spaces.
☒ Never ☐ Occasionally ☐ Constantly

No adverse environmental conditions expected.
☒ Never ☐ Occasionally ☐ Constantly

Physical Demands

Sedentary work that primarily involves sitting/standing.
☐ Never ☐ Occasionally ☒ Constantly

Light work that includes moving objects up to 20 pounds.
☐ Never ☒ Occasionally ☐ Constantly

Medium work that includes moving objects up to 50 pounds.
☒ Never ☐ Occasionally ☐ Constantly

Heavy work that includes moving objects up to 100 pounds or more.
☒ Never ☐ Occasionally ☐ Constantly

Job Type: Full-time

Pay: $75,000.00 - $95,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Vision insurance

Standard shift:

• Day shift

Supplemental schedule:

• On call

Weekly schedule:

• Monday to Friday

Education:

• Bachelor's (Preferred)

Experience:

• Clinical Practice: 2 years (Preferred)
• Case Management: 1 year (Preferred)

Ability to Relocate:

• Towson, MD 21204: Relocate before starting work (Required)

Work Location: Hybrid remote in Towson, MD 21204