Job Summary

Reporting to the Manager of Population Health, the Care Manager (CM) will assist with chronic disease management. The CM will be responsible for the provision of patient-centered nursing care in the primary care setting, helping patients and their families to support the patient’s self-management of chronic conditions. The CM will provide coordinated care to patients by assessing, developing, monitoring, and evaluating interdisciplinary care. This position serves as a patient navigator for chronic care patients and families and may also assume the role of an advocate on the behalf of the patient, The Care Manager also plays an essential role in assisting Total Health Care (THC) in achieving and/or exceeding value based reimbursement payments.

Reporting to the Clinical Manager and/or their designee, the Rich Life Nurse Care Manager is expected to coordinate overall care management for the patients in accordance with the study protocols, while supporting other members of the care team.

Contacts and interactions vary and may involve multiple constituencies such as direct interaction with THC’s executive management, community organizers, the general public, THC’s patients, physicians, colleagues, assigned staff, vendors, contractors and consultants for the purpose of providing and exchanging information.

Example of Essential Job Functions

• Collaborate with multi-disciplinary team to address both physical and psychological aspects of health to provide care for the whole patient.
• Utilize assessment skills to evaluate patient needs and formulate a plan of care, as part of the multi-disciplinary care team
• Coordinate care management for chronic disease and population health
• Revise outcomes and interventions based on results of ongoing evaluation, collaborating with both the patient and members of the care team.
• Identify patients at risk for poor outcomes and those who may require more intensive services such as referral to CHW, THC provider and/or sub-specialists; provide additional outreach and frequent follow up to this population in collaboration with CHW, THC clinical staff and sub-specialists
• Coordinate with community health worker (CHW) to support home visits with patients as needed to address chronic illnesses, and provide education about management and treatment of disease as needed.
• Attend monthly meetings (may be phone conferences) and bi-annual trainings with CHWs and other care managers, as well as, other activities to facilitate optimal care processes.
• Coordinate with the patient, family, and caregivers to resolve barriers to care.
• Support patient education on health promotion, and management of disease.
• Partner with patients in the development of self-management goals, evaluate ongoing status of goals along with other members of the interdisciplinary care team, and coordinate follow-up as needed.
• Evaluate member/family strengths, health behaviors, and resources.
• Collaborate with Referral Coordinator and Population Health Specialist regarding referral needs.
• Provide medication reconciliation and adherence counseling, while assessing patient knowledge and barriers to adherence and self-care
• Participate in continuous quality improvement activities.
• Document all interventions and communication in Electronic Health Record.
• Using appropriate forms, document daily activity related to patient contact and interventions.
• Assist the organization with developing and coordinating health care programs.
• Participate in organizational internal and external outreach events
• Other duties as assigned.

Minimum Education, Training and Experience Required

Graduate from an Accredited School of Nursing

• Current Registered Nursing License
• Preferred: 3+ years of related experience in chronic disease (diabetes, hypertension, heart disease) case management in an ambulatory or acute care setting; BSN
• Must be able to work as part of a multidisciplinary team with constant collaboration within and across provider teams.
• Current BLS certification
• Effectively adapt and respond to a complex, fast-paced, and results-oriented environment
• Significant related experience with populations served may substitute for above requirement.
• Valid Maryland driver’s license and access to an insured automobile that lists employee on the insurance policy.