***
Sign on Incentive:
$7,500 ***
Overview The Care Manager Coordinator delivers and oversees care management services for medically and/or socioeconomically complex patients in the Maryland Primary Care Program (MDPCP) in accordance with patient-defined goals, multi-disciplinary plan of care, and established policies and procedures. Drawing on best practices in motivational interviewing and care management, the Care Manager Coordinator collaborates with clients and multi-disciplinary teams to develop and implement flexible, patient-centered, and cost-effective strategies that support clients to achieve health-related goals.
The Care Manager will collect and analyze patient-level data, assist with development and maintenance of care plans, and evaluate outcomes of interventions. The Care Manager Coordinator also serves as a role model and mentor to staff on best practices in care coordination, motivational interviewing and addressing social determinants of health. This role will supervise other members of the MDPCP Care Team, including the Care coordinator(s) and Case Manager.Key Role Responsibilities
- Oversees care management functions across the Agency including integrating evidence-based practices, collaborating with Care Teams, ensuring equity, and quality of care outcomes. Role includes sharing information with departments and ensuring care management and care coordination activities are integrated into Health Care for the Homeless practice.
- Manages a caseload high-risk patients with chronic conditions, providing complex case management. This may include referrals to chronic disease case management, supporting transitions of care, high risk clinical tracking, and ensuring access to complex medication management.
- Develops and reviews registries regularly and coordinates with external and internal providers regarding health management to inform and support care plans. Works collaboratively with care teams to maximize quality of life as well as reduce avoidable admissions, re-admissions and ED visits. Follows up with MDPCP clients following an ED visit or hospital admission.
- Delivers health education and counseling, drawing upon the individual’s strengths and motivation to explore lifestyle choices, preferences, and safety concerns.
- Perform clinical tasks as appropriate based on license and training.
- Completes clear and timely documentation within electronic health record in a manner that is consistent with MDPCP and agency standards.
- Assesses and addresses the physical, functional, social, psychological, environmental, learning, and financial needs of patients. Involves the client in the development and implementation of an integrated treatment plan.
- Leads and organizes MDPCP-related events and/or health education groups.
Key Agency Responsibilities In addition to role responsibilities, each staff member of Health Care for the Homeless has the following responsibilities as a part of their employment:
- Models and reinforces the Health Care for the Homeless “core values” of dignity, authenticity, hope, justice, passion and balance
- Actively participates in performance improvement activities and actively participates in advocacy activities that support the mission of Health Care for the Homeless
- Performs other duties on an as-needed basis
- Protects our client’s personal health information by maintaining compliance with HIPAA and other relevant Health Care related IT security regulations
Knowledge, Experience and Skills Formal Education and Training
- Possess current licensure as a Registered Nurse in Maryland
- BSN required
- BLS CPR required
- Personal vehicle and valid Maryland driver’s license
Experience
- Two years of clinical nursing
- Two years of case management experience preferred (can be concurrent with clinical experience)
- Experience working with individuals who have behavioral health disorders preferred
- Supervisory experience preferred
Skills
- Able to work well with clients from diverse backgrounds
- Possess strong verbal and written communication skills
- Willingness to integrate principles into practice such as Harm Reduction, Motivational Interviewing and Housing First
- Strong organizational and time management skills
- Able to cope with interruptions and be a team player
- Flexible approach, working with several cross-disciplinary teams in a collaborative style
- Approaches change with a positive, open-minded attitude
- Able to work with ill, disabled, emotionally upset, and sometimes hostile clients
Health Care for
the Homeless is an equal opportunity employer and is committed to racial equity
and inclusion. We make a particular effort to recruit and promote Black,
Indigenous and People of Color (BIPOC) for open positions. BIPOC, LGBTQIA+
individuals, people with disabilities, and people with other marginalized
identities are encouraged to apply.This
is an essential onsite position primarily based at an agency location.
81500.00 To 90468.00 (USD) Annually
