RN Care Manager

Site RN Care Manager (Full Time)

Company: Maryland Primary Care Physicians, LLC
Location: Glen Burnie, MD

Job Type: Full-Time
Salary Range: $93,000 – $113,000 annually
Reports To: Practice Manager, Site Clinical Director, Population Health Clinical Program Manager

Job Summary

The Site RN Care Manager assists in the delivery of high-quality primary care and patient-centered care management. This role focuses on managing patient transitions from hospital to community, chronic disease management, and participation in value-based care initiatives. Responsibilities include patient education, assessment, care planning, evaluation, and coordination of services to improve outcomes and reduce avoidable hospital utilization.

Primary Duties & Responsibilities

• Assist with patient care management, including transitions of care from hospital to home.
• Meet all requirements for the AHEAD Program, MDPCP & Medicaid, and the Medicare EQIP Program.
• Organize, schedule, and facilitate Patient and Family Advisory Council (PFAC) meetings.
• Participate in monthly interdisciplinary team meetings.
• Complete required monthly and program-based reports.
• Access, review, and act on CRISP MDPCP predictive analytics reports for high-risk patients, including:
  • Avoidable Hospital Events (Pre-AH)
  • Severe Diabetes Complications (Pre-DC)
  • Hospice Eligibility and Advanced Care Planning (Pre-HE)
• Maintain required percentages of attributed patients in longitudinal care management with complete documentation in the EMR.
• Develop, document, and update patient care plans and care alerts.
• Provide patient-centered education using motivational interviewing techniques, including social determinants of health assessments.
• Monitor follow-up appointments and assist with scheduling as needed.
• Track and monitor clinical quality measures across providers and sites.
• Collaborate closely with physicians, advanced practice providers, pharmacists, LCSW-Cs, and external specialists.
• Assist with durable medical equipment (DME) orders and home-based care needs during transitions of care.
• Navigate EPIC, email systems, and multiple internet-based care management platforms.
• Use EMR dashboards to track and improve performance related to value-based care and incentive programs.
• Support gap closure initiatives across all payers.
• Maintain and provide vetted community resources, including use of the “Find Help” tool in the EMR and patient portal.
• Participate in quality improvement, safety, and infection control initiatives.
• Attend meetings, trainings, and community events as required.

Knowledge, Skills & Abilities

• Strong knowledge of chronic disease management, medications, diagnostics, and standards of care.
• Proficiency in nursing documentation and EMR systems.
• Ability to work independently while meeting program benchmarks and deadlines.
• Strong communication skills (written, verbal, and electronic).
• Demonstrated ability to multitask and manage multiple ongoing projects.
• Proficiency in Microsoft Office, particularly Excel, for tracking, reporting, and workflow development.
• Ability to establish and maintain effective relationships with patients, providers, and interdisciplinary teams.

Education & Experience

• Education:
  
  • Associate’s Degree in Nursing (required)
  • Bachelor’s Degree in Nursing (preferred)
• Experience:
  
  • Minimum of 3 years of inpatient nursing experience with chronic disease management
  • At least 1 year of care coordination or case management experience

Licensure & Certification

• Active Maryland Registered Nurse (RN) License (required)
• Care Coordination or Case Management Certification (preferred)
  • Must obtain or register to test within 1 year of hire if not already certified

Physical & Working Conditions

• Primarily sedentary with extended periods of sitting and computer use.
• Occasional standing and walking.
• Requires manual dexterity, visual acuity (corrected to 20/40), and hearing within normal range.
• Ability to work in fast-paced, stressful environments with frequent multitasking.
• Possible exposure to communicable diseases and bodily fluids.

Employment Requirements

• MMR and Flu Vaccinations (unless approved for medical or religious exemption)
• PPD test
• Background check and drug screening