Job Description

JOB SUMMARY:

This role coordinates care of the Care Transformation Organization (CTO) assigned Medicare patients within the primary care provider’s office. Works with an interdisciplinary team to manage care and coordinate care services attributed to partisan practices. Assess psychosocial needs and functional deficits of the patient and informs providers of changes in the care plan and/or patient’s condition. Through an integrated approach, this role completes intake assessments, assists with the treatment planning, monitors patient progress, facilitates patient and family meetings, and coordinating and implementing of treatment referrals. This position plans and organizes community-based services that support the patients’ self-management, adherence to treatment plans, and reduction of unnecessary re-hospitalization.

Provides Care Coordination and discharge planning services for all inpatients accessing care through the Univ. of Md. Upper Chesapeake Health. Position needed to cover weekends, some holidays, and weekdays if candidate is available. coverage on Holidays and on back up call system on weekends. May interact with clients or customers ranging in age from newborn to geriatric.

Qualifications

_ Education & Training:_

• Current Maryland RN license required. Completion of a Bachelor’s of Science degree in nursing preferred.
• BLS required.

** Work Orientation & Experience** :

• Three (3) years nursing care experience required. Experience in case management and/or utilization management and ED or outpatient medical practice preferred. Basic computer skills required.

_ Skills & Abilities:_

• Demonstrate skill in a) clinical case management; b) performing complete biopsychosocial assessments and medical triage; c) effective critical thinking; d) written and oral communications; and e) age appropriate interpersonal interactions. Demonstrate knowledge of a) payer (incl. Medicare and Medicaid) regulations and programs; b) general internal medicine topics and c) case management principles. Demonstrate ability to a) communicate and collaborate effectively with both internal and external customers (colleagues, providers, liaisons, and patient/family); b) assess, adapt, and calmly respond to changing and/or crisis environment; c) make independent decisions consistent with current policies, procedures, and ethical standards; d) prioritize work assignments and manage time effectively to complete duties; and e) develop a structured and organized process for monitoring active care plans; f) demonstrate an understanding and sensitivity to serving a culturally diverse population while respecting patient confidentiality; and g) must have reliable transportation.

Additional Information

All your information will be kept confidential according to EEO guidelines.

Compensation:

• Pay Range: $40-$41.2
• Other Compensation (if applicable): N/A
• Review the 2024-2025 UMMS Benefits Guide