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 patient’s knowledge of their clinical condition;
• Provide education and self-management support based on the patient’s 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 patient’s 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