About Us:

Comprehensive Primary Care (CPC) is a collection of twelve office locations offering primary care for every stage of life. We’ve been part of the communities we serve for years – and in some cases decades. Together we strive for healthy neighbors across northern Virginia, eastern Maryland, and the District of Columbia.

The idea behind primary care is to provide a go-to medical home for every patient. We operate much like the old-fashioned generalists of the past – but with a distinctly contemporary approach to medicine. Your CPC primary care providers work to get to know you, your medical history and your needs, and plays an important role as the key first contact in your wellness decisions.

We offer a diverse work experience that empowers colleagues for career success. In addition to skill and experience, we also seek to attract and retain colleagues whose beliefs and behaviors are in alignment with our core values of collaboration, innovation, caring, integrity, and accountability.

Our Values:

• Make health care easily accessible and readily
• Maintain a welcoming environment for all
• Listen to and respect the unique needs of each patient
• Respond quickly and maintain open, multi-level communication with each patient
• Encourage whole families, extended families and friends to take charge of their health
• Provide consistent high-quality health care
• Invest in professional development for providers and staff
• Maintain a safe and supportive working environment for all

About the Role:

The Population Health Nurse is responsible for the implementation of Comprehensive Primary Care’s (CPC) Population Health services program with diverse job functions designed to meet specific contractual and program related requirements. This role focuses on improving the health status and care for individuals with chronic conditions: potentially complex medical, mental health, and psychosocial issues: and implementing the utilization review, clinical review plan approvals, discharge planning, and transitional case management processes for individuals covered by health plans who have delegated the responsibility to Comprehensive Primary Care.

Requirements for the Role:

Essential Functions

Care and Condition Management

• Carries out transitional care management program.
• Conducts chronic condition management for individuals with target chronic conditions.
• Conducts outreach through face-to-face follow-up, by telephone, secure e-mail, or postal mail with goal of engaging enrollee.
• Assesses individual needs and develops plans to address needs/issues related to conditions and/or overall health
• Actively participates with community-based initiatives related to care management and transitions of care.
• Conducts patient education regarding condition and symptom management, red flag warning signs, the importance of adhering to medications and evidence-based guidelines, and refers to customer-sponsored or community supported programs.
• Establishes self-management goal(s) with patients using self-management support concepts and motivational interviewing techniques

Utilization Management

• Using the nursing process, conducts prospective, concurrent and retrospective review activities for uncomplicated and complex cases for healthcare facilities.
• Coordinates and communicates with health plans as appropriate.
• Carries out transitional case management program for uncomplicated and complex cases through avoidance of hospitalization or facilitating the timely discharge of hospitalized members including discharge planning.

Additional Responsibilities

• Applies the principles of the nursing process to care and condition management of individuals with chronic conditions and those needing transitional care coordination.
• Assists in provider and office staff education regarding Population Health initiatives.
• Identifies opportunities for continuous improvement, develops related plans of action, and implements process and documentation improvements.

FLSA: Exempt

Education/Experience (Minimum Requirements):

Registered Nurse and Bachelor’s degree in nursing.
Certified Case Management or Chronic Case Nurse preferred.

Specific Knowledge, Skills, Licenses, Certifications, Etc:

Experience:

Three years clinical nursing experience in acute case setting. Additional experience in ambulatory care, home health, physician practice, utilization management, or other community setting preferred.

Skills:

Ability to communicate orally and in writing clearly and assertively.
Ability to analyze, plan, think critically and problem-solve effectively.
Ability to organize, prioritize, and be flexible.
Ability to work within a variety of teams.
Strong attention to detail.
Demonstrate and maintain high level of accuracy.
Proven customer relations skills.

Licensure:

RN with current Maryland license in good standing .

The above statements are intended to describe the general nature and levels of the work performed and are not exhaustive lists of all duties, responsibilities, knowledge, skills, and abilities and working conditions associated with the job. As changes occur CPC reserves the right to modify the above description.

Work Location: Rockville, MD/In person

Medical Clearance:

You must complete Comprehensive Primary Care’s medical clearance requirements, which include, but may not be limited to, evidence of Hepatitis B, Pneumococcal screen, and a Tuberculosis screen, or have an approved medical or religious accommodation that precludes you from being vaccinated against these diseases.

Comprehensive Primary Care values diversity as a core tenet of the work we do and the populations we serve. We are an equal opportunity employer, indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.
We consider an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for health insurance, life insurance, retirement benefits, paid time off, including vacation and holiday pay. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location.