1. General Summary

Responsible for identifying member gaps in care and implementing solutions to remediate them. Work closely with the RN Care Manager and other members of the Interdisciplinary Care Team to address post discharge and post-acute care needs, coordinate referrals and address social determinants of health. Provide a variety of administrative services to an assigned organizational unit. Work is performed under moderate supervision. Director report to the Nurse Manager, Population Health.

1. Principal Responsibilities and Tasks
   The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

• • Contact members by phone, mail and/or in person to educate them about their health care needs, gaps in care and the importance of closing those gaps.
  • Execute tasks for effective care coordination to improve patient care such (e.g., schedule follow-up visits and labs/tests, communicate with providers and case managers, and facilitate referrals and utilization, etc.).
  • Prepare documents and various materials, responds to correspondence and telephone inquiries, maintains filing systems, and prepares basic statistical data and reports.
  • Utilize various reports and data bases to assign cases to members of the care team.
  • Assist with health screenings and assessments and supports patient education related to social and health needs.
  • Provide scripted education/coaching and distribute health education materials (utilizing department approved resources) to patients and family members, as needed.
  • Screen patient using validated tools such as high-risk screeners, social determinants of health and PHQ 2-9.
  • Identify members who could benefit from case management and make appropriate referrals to the CM Program.
  • Conduct Transition of Care phone call to patients experiencing a transition along a care continuum such as post Emergency Department /hospital discharge, or post-acute care.
  • Work with the Interdisciplinary Care Team to provide support services and coordination of care activities to a defined population (e.g., post discharge phone calls, outreach phone calls to moderate and rising risk patients for screening into services, wellness checks, and education and follow up on care plan goals, etc.).
  • Provide education regarding scheduling routine wellness and screening appointments.
  • Adhere to standard volume of follow-ups, communicated productivity metrics, including length of call, length of answer time, and the number of calls taken or delivered to achieve first call resolution on every call.
  • Perform data entry in accordance with quality standards, including appropriate documentation and communication in accordance with compliance and regulatory requirements.
  • Manage a high-volume of inbound or outbound communication verifying and/or securing primary care visits, insurance coverage, etc.

• • Document the patient medical record and/or care management application.
  • Maintain HIPAA standards and ensure confidentiality of protected health information.
  • Perform other duties as assigned.

Renowned as the academic flagship of the University of Maryland Medical System, our Magnet®-designated facility is a nationally recognized, academic medical center with opportunities across the continuum of care. Come join UMMC and discover the atmosphere where talents and ideas come together to enhance patient care and advance the science of nursing. Located in downtown Baltimore near the Inner Harbor and Camden Yards, you won’t find a more vibrant place to work! 

1. Education and Experience
   • High School Diploma.
   • Associate degree in a healthcare related field preferred.
   • Minimum two (2) years’ experience in care management, coaching or community health work.
   • Minimum two (2) years’ experience working in a client service environment.
   • Certification in Community Health Work, Medical Assistant, Pharmacy Technician, or related health field, or the ability to obtain within one (1) year of start date.
   • Valid driver’s license and reliable transportation (may be required to use personal vehicle for offsite visits).

IV. Knowledge, Skills, and Abilities

• • Working knowledge of basic medical terminology and concepts used in care management.
  • Working knowledge of population, demographics, assets, and needs.
  • Working knowledge of chronic health conditions and associated self-care.
  • Working knowledge of social determinants of health disparities.
  • Working knowledge of applicable federal, state, and local laws, rules, and regulations (e.g., HIPPA).
  • Ability to educate members regarding community resources.
  • Ability to think critically and follow a plan of care.
  • Advanced customer service skills.
  • Proficient documentation skills to maintain client records.
  • Ability to analyze, compare, contrast, and validate work with keen attention to detail.
  • Effective interviewing, listening, and coaching skills.
  • Demonstrated resourcefulness, with ability to anticipate needs, prioritize responsibilities and take initiative.
  • Effective skill to influence, negotiate and persuade to reach agreeable exchange and positive outcomes.
  • Effective analytical, critical thinking, planning, organizational, and problem-solving skills.
  • Ability to communicate effectively in person, by phone, and by email.
  • Ability to work independently and as part of a team.
  • Advanced verbal, written and interpersonal communication skills.
  • Advanced skill in the use of Microsoft Office Suite (e.g., Outlook, Word, Excel, PowerPoint).

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