The Care Manager will work with Aledade primary care practices in Maryland as a part of the Maryland Primary Care Program. The care manager collaborates with the care team within each practice and leverages Aledades interdisciplinary care team to provide telephone-based health coaching quality improvement and care coordination. The care manager works closely with Medicare patients to support them in becoming active in their health care by better understanding their chronic conditions helping them access care in the most appropriate setting and improving quality of care. Care managers utilize Aledades proprietary population health tool the Aledade App to manage high-risk patients using real-time data to identify and intervene on high utilizers who could benefit from more preventative and active management.
This position is remote but will require travel to your assigned practices once a month and you will travel periodically to work related team retreats and events.
Primary Duties:
Conduct comprehensive assessments that include the medical behavioral pharmaceutical and social needs of the patient identify and address gaps in care and barriers to attaining improved health; Assess the patients knowledge of their clinical condition;
Provide education and self-management support based on the patients unique learning style; Work with the patient and their caregiver to increase their self-efficacy and ability to play a central role in their care; Coordinate care by serving as the advocate and resource for the patient their family and their physician building effective relationships in the community and across the continuum of care; provide patients with care transition planning support and follow up;
Collaborate with the patients primary care physician and care team if applicable to identify high-risk patients and design appropriate care plan interventions; participate in and help facilitate periodic complex care rounds with interdisciplinary care team;
Provide clinical oversight to non-licensed support staff (e.g. health coaches patient navigators community health specialists etc.) and delegate supportive tasks as appropriate;
Support implementation of Aledade initiatives that support population health care management (vendors for end of life care virtual behavioral health etc.). Measure improve and maintain quality outcomes (clinical financial and functional) for individual patients and the population served; understand the requirements and intent of the Maryland Primary Care Program and develop and execute care plans focused on reducing unnecessary hospital and specialist utilization and improving quality.
Required Qualifications:
Current Registered Nurse in Maryland
3-5 years of direct healthcare experience preferably in home health ambulatory care community public health case management or care coordination across multiple settings with multiple providers
Preferred Key Skills and Abilities:
Familiarity with the healthcare community we are serving or commitment to learn and understand through on the ground networking community assessment etc.
Population health and/or managed care experience
Understanding of quality metrics
Knowledge and experience activating patients and teaching self-management skills
Experience working with vulnerable populations (geriatrics minorities behavioral health)
Ability to navigate ambiguity with the aid of structured problem-solving techniques
Exceptional communication skills both written and oral ability to positively influence others with respect and compassion
Strong work ethic built on a foundation of proactivity collaboration and teamwork
Committed to the practice of inquiry and listening
Competent documenting in electronic health records
Demonstrates curiosity of learning and receiving critical feedback to further growth and development
Physical Requirements:
Sedentary work on telephone and computer with repetitive movements
Finger dexterity
Proficient communicative auditory and visual skills
Ability to travel to practices if needed and travel to work related team retreats
$85000 - $85000 a year
Salary is $85000 base bonuses equity
Compensation for the role will depend on a number of factors including a candidates qualifications skills competencies and experience.
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