Education:
Registered Nurse license required. Bachelor's of Science in Nursing preferred.
Experience:
This position requires extensive knowledge of disease management to include diagnostics, treatment and prognosis, community resources, and levels of care throughout the care continuum. 1-2 years of clinical experience is preferred, but not required. Relevant experience in one or more of the following healthcare areas preferred:
- Coordination of community resources
- Care Management of diverse patient populations
- Familiarity with care in an ambulatory setting
Working knowledge of Care Management models especially in the State of Maryland
Skills:
* Clinical Assessment, interviewing and patient education skills
* Participates in data collection, analysis, and reporting to facilitate comprehensive evaluation of program impact and areas to take action.
* Skill in oral and written communication to address inter- and intradepartmental concerns, solve problems, and address conflict.
* Demonstrated skill in problem solving using available resources in innovative ways.
* Computer and personal productivity skills to enable effective job performance.
* Maintains knowledge of professional standards of practice through participation in continuing education, community and professional activities, and committee membership.
* A compassionate and empathetic demeanor and a can-do attitude.

Principal Duties and Responsibilities:
Care Management
* Assesses patients within a defined caseload to identify clinical/medical needs or issues, financial resources, and care goals. Continues assessment of patient care management needs through frequent contact and communication with care team, patient and family.
* Actively manage assigned panel of chronic care patients (high acuity/complex) by: developing relationships with the patient as an integral member of the team and providing follow-up contact with patient as indicated to ensure compliance with recommendations-medications, lab/x-ray, specialist visits, PCP visits, dieticians, CDE, etc.
* Execute standing orders for tests and preventive services.
* Manage many aspects of the patient's care to include referrals to specialist, hospitalizations, ER visits, ancillary testing, and other services. Responsible for being available to provide telephone advice per protocol, handle urgent calls and emergent calls. Anticipate the needs of this patient population, seeing that the necessary documentation and pre-visit planning is completed or requested before patient visit.
* Prioritizes care management activities in order of greatest patient need and system need to achieve optimum quality and cost outcomes.
* In conjunction with the patient, provider, care coordinator, behavioral health care manager (BHCM), 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.
* Develops and implements plan for assessment, education, goal setting and tracking outcomes.
* Reports at APC meetings providing provider care transformation metrics. Provides quality reports at meetings (e.g. patient satisfaction, quality metrics, etc.)
* Attends monthly meeting dates with providers and key staff. Provides quality reports at meetings (e.g. patient satisfaction, quality metrics, etc.)
* Participates in practice strategy and for performance improvement and innovation and LMS
* Work with all clinical teams as a resource on care management of assigned patients of the practice to include: pre-visit planning workflow to ensure care completion prior to visit whenever possible, after visit summary review with patients whenever appropriate, patient engagement to involve the patients in activities to improve their health, and patient education about self-management tasks they can undertake to gain greater control of their health status
* Collaborate with MIS team to facilitate registry reporting at the site and documentation of Evidence Based Guidelines in searchable fields.
* Serve as a resource to clinical staff and providers to establish quality goals using reports.
* Responsible for working with patient and patient's care team to coordinate change readiness, needs assessment and develop an individualized care plan. Assist patients in setting SMART goals for self-management, teaching them self-management tasks and report abnormal findings to their physician/provider led clinical team.
* Collaborates with the patient, providers, and other care team members (BHCM, Substance Use Consultant, Psychiatrist, Geckle, Gilchrist, etc.) in assessing the patient's progress toward individual health care goals.
* 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
* Oversees the development, and adoption of patient self-management educational resources used by the primary clinical teams.
* Collaborate with payer Case Managers for additional services when appropriate. (Carefirst LCCs, etc.)
* Develops and maintains relationships with the entities used most frequently.
* Work with MIS team to coordinate efficient consult request communication and consistent documentation of patient self-management measures, mutually agreed upon care plan that is efficiently available to all and reporting of progress towards goals.

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 privacy

• Listens 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 expectations
• Actively pursues learning and self-development
• Pays 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 others
• Takes ownership of problems and does what is needed to solve them
• Appropriately plans and utilizes required resources for various job duties
• Reports 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 team
• Addresses and resolves conflict in a positive way
• Seeks out the ideas of others to reach the best solutions
• Acknowledges 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 judgment
• Respects 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 environment
• Continuously seeks to improve the quality of products/services
• Displays flexibility in dealing with new situations or obstacles
• Achieves 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.