The RN Care Manager's primary responsibilities are to oversee care management and coordination of clinical activities for a defined patient population and to promote population health management through effective education, self-management support, goal setting, care planning and timely health care delivery. This will include developing and monitoring care management processes and support for primary clinical teams with these efforts. The Nurse Care Manager will work cooperatively with the Practice Manager, Lead Physician Provider of the practice, Care Coordinator, Centralized Care Coordinator(s) and Behavioral Health Consultant(s) to best serve the needs of the identified patient panel. The RN Care Manager will serve as a clinical resource in the primary care setting.

Education:
Bachelors of Science in Nursing required
Licensures/Certifications:
Current registration with the Maryland State Board of Examiners of Nurses as RN
Completion of “Healthcare Provider” CPR
Certificate or Certification in specialty related to your current practice within 3 years of hire
Experience:
At least 2 years of diversified, progressive experience in acute care and/or other settings within the continuum. Ambulatory Care Management experience a plus
Skills:
• Clinical assessment of patients including but not limited to; Social Determinants of Health, care planning, motivational interviewing, and patient education skills
• Proficiency in developing a detailed and comprehensive nursing plan of care for patients with multiple comorbidities, high risk and rising risk patients, high utilizers, the implementation of effective nursing care, patient education, metrics, LDM, evaluating data, metrics and the outcome of nursing interventions
• Analytical skills necessary to prepare and interpret reports
• Effective planning and organizational skills to effectively manage multiple priorities simultaneously
• Skills in oral and written communication to address inter- and intradepartmental concerns, problem solving and the ability to address patient needs and Social Determinants of Health
• Demonstrates problem solving skills, the ability to research and evaluate innovative ways to use community resources
• Computer, data analysis and personal productivity skills to enable effective use of EMR, e-mail, the internet, word processing, spreadsheets, presentations, and database packages
• The ability to cover other practices and multiple practices, as needed.

Principal Duties and Responsibilities:
Clinical Practice/Care Management
• Assesses patients within a defined patient panel to identify clinical/medical needs or issues and care goals. Continue assessment of patient care management needs through care planning, frequent contact, huddles, and communication with the entire care team, patient and family
• Actively manage a defined patient panel of patients with chronic conditions and multiple comorbidities (high acuity/complex). This will include, but not be limited to:
o Care planning; assist patients in setting SMART goals for self-management, teaching them self-management tasks
o Addressing urgent referrals to specialists and/or imaging
o Following-up to ensure compliance with recommendations-medications, lab/x-ray, specialist visits, PCP visits, dieticians
o Following-up with patient after hospitalizations/ER visits, in accordance with policies and procedures
o Execute standing orders for tests and preventive services
• Anticipate the needs of a defined patient panel by preparing for and participating in a care team “huddle”. This should include seeing that the necessary documentation and pre-visit planning is completed or requested before patient visit
• Works collaboratively with practice manager, providers, care coordinators, behavioral health consultants, and others, as needed in managing a defined panel of patients. Assess barriers and link to alternate resources when patient has not met treatment goals, is not following treatment plan of care, or has not kept important appointments
• Work with the care team to prevent unnecessary utilization through the following:
o Utilizing CRISP: Notification system for ED and hospital admissions
o Collaborating with the providers and care coordinators to develop a plan of care to reduce hospital visits for a defined
patient panel
o Works in collaboration with the inpatient Care Management team to ensure warm handoffs are provided for patients
coming to the ED, hospital or who have recently been discharged from the hospital
• Handle urgent on-call patient needs after hours, in accordance with on-call policy
• In conjunction with the patient, provider, care coordinator, behavioral health consultant, family and other members of the
healthcare team, the payer and available resources makes referrals for transitions in care for the patient population that he/she
manages
• Monitor population management data and reports to ensure patients’ health and social needs are being addressed. Develop targets to improve and/or action plans for areas in need of improvement
• Prioritizes care management activities in order of greatest patient need and system need to achieve optimum quality and cost outcomes. Meet productivity standards
• Attends staff and committee meetings including office based Advanced Primary Care/PCMH meetings and care management meetings
• Utilizes Quality Improvement plan for reporting and improvement strategies (PDSA & LDM)
• Utilizes Lean Daily Management and metrics for reporting quality improvement strategies

All roles must demonstrate GBMC Values:

Respect

I will treat everyone with courtesy. I will foster a healing environment.

Treats others with fairness, kindness, and respect for personal dignity and privacyListens and responds appropriately to others’ needs, feelings, and capabilities

Excellence

I will strive for superior performance in every aspect of my work. I will recognize and celebrate the accomplishments of others.

Meets and/or exceeds customer expectationsActively pursues learning and self-developmentPays attention to detail; follows through

Accountability

I will be professional in the way I act, look and speak. I will take ownership to solve problems.

Sets a positive, professional example for othersTakes ownership of problems and does what is needed to solve themAppropriately plans and utilizes required resources for various job dutiesReports to work regularly and on time

Teamwork

I will be engaged and collaborative. I will keep people informed.

Works cooperatively and collaboratively with others for the success of the teamAddresses and resolves conflict in a positive waySeeks out the ideas of others to reach the best solutionsAcknowledges and celebrates the contribution of others

Ethical Behavior

I will always act with honesty and integrity. I will protect the patient.

Demonstrates honesty, integrity and good judgmentRespects the cultural, psychosocial, and spiritual needs of patients/families/coworkers

Results

I will set goals and measure outcomes that support organizational goals. I will give and accept help to achieve goals.

Embraces change and improvement in the work environmentContinuously seeks to improve the quality of products/servicesDisplays flexibility in dealing with new situations or obstaclesAchieves results on time by focusing on priorities and manages time efficiently

COVID-19 Vaccination

All applicants must be fully vaccinated against Covid-19 or obtain a GBMC approved medical or religious exemption prior to starting employment at GBMC Healthcare, to include Gilchrist and GBMC Health Partners.

Equal Employment Opportunity

GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.