About this role
DUTIES:
Manage care Transitions from ER, Hospital and Nursing Home, coordinated with primary care provider staff and hospital staff
Individual Care Planning for High Risk Patient and Prevention/wellness visits - coordinate efforts with payer/vendor care manager(s) team, primary care provider and his support team as well as community resources
Coordination of Clinical Quality Improvement (CQI) Activities
Coordinates, provides and documents patient education plan using standard based practice guidelines. Interacts effectively with patients, providing instruction and information, both written and verbal, as appropriate. Validates patients understanding of care/intervention recommendations.
Provides training and updates on EMR usage and workflow
NECESSARY ATTRIBUTES:
Exceptional oral and written communication skills
Strong interpersonal skills
Demonstrated ability to collaborate effectively in team setting
Basic computer skills
Ability to effectively engage patients
QUALIFICATIONS:
Current valid and unrestricted medical license in the State of Maryland (LPN, RN)
2+ years of direct practice experience in settings that include inpatient, partial, and/or outpatient preferred
Working knowledge of value based care models such as ACO’s, PCMH, and MACRA/MIPS
The ideal candidate is someone who is always looking to do more, be a great asset to the team, and provide excellent patient care. He or she is a self-starter and does not wait to be directed to perform daily functions. In order to be successful in this position you have to be an outgoing and driven individual who is compassionate to the needs of others.