Care Manager

Aledade, Inc. - Cambridge, MD

Full-timeEstimated: $62,000 - $76,000 a year
Skills
Founded in 2014, Aledade is a healthcare company funded by Venrock, ARCH Venture Partners, Biomatics Capital and Google Ventures. We help independent primary care physicians deliver better care at lower cost by supporting their transition to value based care for their Medicare and commercial patient populations. Our rapidly expanding national network includes more than 1,400 primary care physicians and 330,000 patients, with $2.5 in annual medical spending under management.

In 2018, powered by a diverse, dynamic, passionate team of over 200 employees who are committed to changing healthcare in America, Aledade was named a Washington Post Top Workplace in 2018 and was also selected as a finalist for the Top 50 in Digital Health’s Fastest Growing Company.

Are you an experienced clinical RN, LPN, LCSW, or similar and interested in an exciting career in care management? Do you have experience working for an FQHC? Are you passionate about helping patients stay healthy and at home where they want to be? Do you excel at coordinating care across care settings and improving quality? If so, this is the position for you!

Aledade is recruiting care managers who will work inside of primary care practices in Salisbury and Cambridge, Maryland. As part of the new Maryland Primary Care Program, care managers will collaborate with the care team within each practice and leverage Aledade’s interdisciplinary care team to provide telephone-based health coaching, quality improvement, and care coordination. You will work closely with your 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 care setting, and improving quality of care. You will use Aledade’s proprietary population health tool, the “Aledade App,” to manage your high-risk patients, using real-time data to identify and intervene on high utilizers who could benefit from more preventive and active management.

Responsibilities

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;
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;
Collaborate with the patient’s primary care physician and care team if applicable, to identify high-risk patients and design appropriate interventions.
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;
Assess the patient’s knowledge of their clinical condition and provide education and self-management support based on the patient’s unique learning style;
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
Work with the patient and their caregiver to increase their self-efficacy and ability to play a central role in their care;
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
Qualifications

Required

Degree or Licensure in Maryland
3-5 years of direct healthcare experience, preferably in home health, ambulatory care, community public health, case management, or care coordination across multiple settings and with multiple providers
Current Registered Nurse, LPN, or Social Work license
Preferred

Familiarity with the healthcare community we are serving or commitment to learn and understand through on the ground networking, community assessment, etc.
Population health and/or managed care experience
Understanding of quality metrics
Knowledge and experience activating patients and teaching self-management skills
Experience working with vulnerable populations (geriatrics, minorities, behavioral health)
Ability to navigate ambiguity with the aid of structured problem-solving techniques
Exceptional communication skills, both written and oral, ability to positively influence others with respect and compassion
Strong work ethic built on a foundation of proactivity, collaboration, and teamwork
Committed to the practice of inquiry and listening
Competent documenting in electronic health records
Demonstrates curiosity of learning and receiving critical feedback to further growth and development
At Aledade, we don’t just accept differences, we celebrate them. We strive to attract, develop, and retain highly qualified individuals representing the diverse communities where we live and work. Aledade is committed to creating a diverse environment and is proud to be an equal opportunity employer. Employment policies and decisions at Aledade are based on merit, qualifications, performance, and business needs. All qualified candidates will receive consideration for employment without regard to age, race, color, national origin, gender (including pregnancy, childbirth or medical condition related to pregnancy or childbirth), gender identity or expression, religion, physical or mental disability, medical condition, legally protected genetic information, marital status, veteran status, or sexual orientation