Job Summary

o Responsible for the care management and care coordination of Medicare beneficiaries attributed to a medical practice(s). Minimum Qualifications

Education/Training

• Bachelor’s Degree in Nursing (BSN).

Experience

• 1 or more years of experience as RN or case management project management and population health coordination experience. Experience with data collection and reporting preferred. Experience working in an ambulatory setting preferred.

License/Certification/Registration

• Registered Nurse licensed in Maryland required. Certified Case Manager (CCM) from a nationally recognized certification agency preferred or will obtain CCM certification within 12 months of the date of hire.

Knowledge, Skills & Abilities

• Effective verbal and written communication skills. Excellent interpersonal and customer service skills especially serving geriatric patients. Strong analytical and critical thinking skills. Strong community engagement and facilitation skills. Advanced project management skills. Commitment to collective impact concepts. Flexibility and the ability to work autonomously as well as take direction as needed. Cultural competency. Proficient computer skills along with experience using Microsoft applications-Word, Excel, etc. and familiarity with entering data in an electronic medical record (EMR).

Primary Duties and Responsibilities

• Under the direction of the practice physician, performs direct patient care including wellness visits, transitional care, administer vaccinations, screenings, etc.
• Assesses, plans, implements, monitors and evaluates options and services to meet health needs of attributed beneficiaries. Manages a caseload in compliance with contractual obligations and the MD Primary Care Program (MDPCP) standards.
• Conducts comprehensive member assessments through root cause analysis based on member's needs and performs clinical intervention through the development of a care management treatment plan specific to each member with high level acuity needs.
• Monitors and evaluates effectiveness of care plan and modifies plan as needed. Supports member access to appropriate quality and cost effective care. Coordinates with internal and external resources to meet identified needs of the member's care plan and collaborates with providers.
• Acts as a liaison and member advocate between the member/family, physician and facilities/agencies. Provides clinical consultation to physicians, professional staff and other teams members/supervisors to provide optimal quality patient care and effective operations.
• Interacts continuously with members, family, physician(s), and other resources to determine appropriate behavioral action needed to address medical needs. Reviews benefits options, researches community resources, trains/creates behavioral routines and enables members to be active participants in their own healthcare.
• Ensures members are engaging with their PCP to complete their care management treatment plan or preventive care services.
• Performs other duties as assigned.

SOUTHERN MARYLAND MEDICAL GROUP IS AN EQUAL OPPORTUNITY EMPLOYER.

Job Type: Full-time

Pay: $30.00 - $38.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Flexible schedule
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift

Work Location: In person