Care Manager, RN

The Care Manager will work with Aledade primary care practices in Maryland as a part of the Maryland Primary Care Program. The care manager collaborates with the care team within each practice and leverages Aledade's interdisciplinary care team to provide telephone-based health coaching, quality improvement, and care coordination. The care manager works closely with Medicare patients to support them in becoming active in their health care by better understanding their chronic conditions, helping them access care in the most appropriate setting, and improving quality of care. Care managers utilize Aledade's proprietary population health tool, the "Aledade App" to manage high-risk patients, using real-time data to identify and intervene on high utilizers who could benefit from more preventative and active management.

Primary Duties :

• Conduct comprehensive assessments that include the medical, behavioral, pharmaceutical and social needs of the patient, identify and address gaps in care and barriers to attaining improved health; Assess the patient's knowledge of their clinical condition;
• Provide education and self-management support based on the patient's unique learning style; Work with the patient and their caregiver to increase their self-efficacy and ability to play a central role in their care; Coordinate care by serving as the advocate and resource for the patient, their family, and their physician, building effective relationships in the community and across the continuum of care; provide patients with care transition planning support and follow up;
• Collaborate with the patient's primary care physician and care team if applicable, to identify high-risk patients and design appropriate care plan interventions; participate in and help facilitate periodic complex care rounds with interdisciplinary care team;
• Provide clinical oversight to non-licensed support staff (e.g. health coaches, patient navigators, community health specialists, etc.) and delegate supportive tasks as appropriate;
• Support implementation of Aledade initiatives that support population health care management (vendors for end of life care, virtual behavioral health, etc.). Measure, improve and maintain quality outcomes (clinical, financial, and functional) for individual patients and the population served; understand the requirements and intent of the Maryland Primary Care Program, and develop and execute care plans focused on reducing unnecessary hospital and specialist utilization and improving quality.

Required Qualifications :

Preferred Key Skills and Abilities :

Physical Requirements :

Salary is $85,000 base bonuses equity

Compensation for the role will depend on a number of factors, including a candidate's qualifications, skills, competencies and experience.

PDN-9d79e6ef-6df3-435a-99b5-d722e80adb90

Salary : $85,000