RN Care Manager
About the role
The Maryland Primary Care Program (MDPCP AHEAD) RN Care Coordinator will work closely with Primary Care providers to manage patients with multiple chronic conditions.
Responsibilities
- Identify, screen, track, monitor, and coordinate the care of patients with multiple chronic conditions.
- Develop and deliver comprehensive primary care to patients.
- Interact and collaborate with interdisciplinary care teams, population health teams, networked facility partners, physicians, and others involved in meeting the patient’s needs.
- Ensure high quality care for patients by reviewing and researching concerns or complaints and recommending corrective action as appropriate.
- Identify and recommend solutions to issues and problems.
- Maintain excellent communication and effective working relationships with patients, office managers, providers, and clinical team members.
- Collaborate with assigned local teams to meet Maryland Primary Care Program (MDPCP AHEAD) 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.
- Provide Transitional Care Management including, but not limited to, post in-patient and/or emergency department discharge follow up.
- Provide education and assistance as it relates to lifestyle coaching, dietary improvements and plans.
- 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.
- Attend and participate in regular care team meetings to discuss patient care.
Qualifications
- Active RN License.
- 2+ years of population health or care coordination experience.
- Pediatric experience preferred.
- Strong computer and EHR skills and expertise.
- Preferred experience with Medicaid patients in a value-based program.
- Preferred experience educating and engaging patients.
- Experience working in an outpatient medical office.
- Must comply with all HIPAA rules and regulations.
- Bilingual candidates are encouraged to apply (especially those who speak Spanish).
Skills
- Excellent communication and interpersonal skills.
- Strong problem-solving and critical thinking abilities.
- Effective collaboration and teamwork.
- Ability to work independently and manage multiple tasks.
Benefits
Privia Health offers a competitive compensation package including a base salary ranging from $75,000.00 to $85,000.00 in base pay and exclusive of any bonuses or benefits (medical, dental, vision, life, and pet insurance, 401K, paid time off, and other wellness programs). This role is also eligible for an annual bonus targeted at 10%.
Pay
$75,000.00 to $85,000.00 in base pay
Schedule
Full-time, remote position
Technical Requirements
To successfully work remotely, supporting our patients and providers, we require a minimum of 5 MBPS for Download Speed and 3 MBPS for the Upload Speed. This should be acquired prior to the start of your employment. The best measure of your internet speed is to use online speed tests like https://www.speedtest.net/. This gives you an update as to how fast data transfer is with your internet connection and if it meets the minimum speed requirements. Work with your internet provider if you have questions about your connection. Employees who regularly work from home offices are eligible for expense reimbursement to offset this cost.