Description:
RN Care Manager – Population Health
Maryland Primary Care Physicians, LLC
Position Summary
Maryland Primary Care Physicians (MPCP) is seeking a highly motivated and patient
focused Registered Nurse (RN) Care Manager to support the organization’s Population
Health and Value-Based Care initiatives. This role is responsible for coordinating
comprehensive care management services for high-risk, medically complex, and
chronically ill patients attributed to the Maryland Primary Care Program (MDPCP)/AHEAD
model and other value-based care contracts, across multiple payer programs and
population health models.
The RN Care Manager plays a critical role in improving clinical outcomes, reducing
avoidable healthcare utilization, supporting care transitions, closing gaps in care, and
enhancing the overall patient experience. Working collaboratively within an
interdisciplinary team, the RN Care Manager provides patient education, care
coordination, chronic disease management, motivational interviewing, and community
resource support to promote patient engagement and long-term wellness.
This position requires strong clinical judgment, organizational skills, population health
knowledge, and the ability to effectively manage multiple priorities in a fast-paced primary
care environment.
Requirements:
Key Responsibilities
Population Health & Value-Based Care:
- Support organizational initiatives related to population health, value-based care, and alternative payment models, including the Maryland Primary Care Program (MDPCP)/AHEAD model, other value-based care contracts, Medicaid, Medicare EQIP, and other payer-based programs.
- Utilize predictive analytics, population health reports, registries, and payer data to identify and proactively manage high-risk, high-utilization, and medically complex patients.
- Review and act on CRISP and other population health reporting tools, including predictive analytics related to avoidable hospital events, severe diabetes complications, hospice eligibility, and advanced care planning.
- Monitor and support site and provider performance related to quality metrics, preventive care, chronic disease management, and gap closure initiatives.
- Collaborate with Population Health leadership and analytics teams on monthly, quarterly, and annual reporting, quality improvement initiatives, patient engagement strategies, and performance optimization.
- Participate in Quality Improvement (QI), Safety, and Infection Control initiatives as directed by the Population Health team.
- Identify common patient needs and barriers among attributed patient populations and assist in developing interventions and resource strategies to improve outcomes.
Care Management & Care Coordination:
- Provide longitudinal care management services for patients with chronic conditions, complex medical needs, and behavioral or social barriers to care.
- Conduct comprehensive patient assessments and develop individualized care plans, action plans, and goals in collaboration with patients, caregivers, and providers.
- Coordinate transitions of care following hospitalizations, emergency department visits, and skilled nursing facility discharges to reduce readmissions and improve continuity of care.
- Utilize motivational interviewing techniques and patient-centered communication strategies to support self-management and patient engagement.
- Assist patients with scheduling appointments, follow-up care, medication adherence, and coordination of specialty referrals and home-based services.
- Collaborate closely with physicians, advanced practice providers, pharmacists, behavioral health providers, care managers, and community organizations to ensure coordinated, team-based care.
- Facilitate referrals to internal and external resources, including social work, behavioral health, specialty care, durable medical equipment (DME), and community support services.
- Maintain and utilize current community resource directories and EMR-based resource tools to address social determinants of health and support patient needs.
Documentation & Program Compliance:
- Maintain accurate, timely, and compliant documentation within the electronic medical record (EMR), including care plans, care management episodes, and patient outreach activities.
- Document care alerts and interventions appropriately within the EMR to support continuity of care.
- Monitor and maintain required program participation metrics and documentation standards for attributed patient populations.
- Navigate and effectively utilize EPIC, population health dashboards, CRISP reports, payer portals, and other web-based platforms used in patient care management.
- Attend interdisciplinary meetings, educational sessions, and community outreach events as required.
- Organize, schedule, and lead Patient and Family Advisory Council (PFAC) meetings as required.
- Perform additional duties and responsibilities as assigned.
Qualifications
Education
- Graduate of an accredited school of nursing with a minimum of an Associate Degree in Nursing required.
- Bachelor of Science in Nursing (BSN) preferred.
Licensure & Certifications
- Active Registered Nurse (RN) license in the State of Maryland required.
- Active nationally recognized Care Manager certification (e.g., Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or Certified in Care Coordination and Transition Management (CCCTM)) required, or willingness to obtain certification within one (1) year of hire.
Experience
- Active clinical nursing background in inpatient, ambulatory, or chronic disease management settings required, in addition to the case management experience noted below.
- Three (3) to five (5) years of case management experience required, preferably in care coordination, population health, or value-based care settings.
- Experience working with Epic EHR, quality reporting systems, and population health platforms (eg, CRISP) strongly preferred.
Knowledge, Skills & Abilities
- Strong understanding of population health, chronic disease management, transitional care management, and value-based care principles.
- Knowledge of clinical quality measures, preventive care guidelines, and healthcare utilization management.
- Ability to interpret and utilize population health data, registries, dashboards, and predictive analytics reports.
- Excellent patient assessment, care planning, communication, and motivational interviewing skills.
- Ability to establish and maintain effective working relationships with patients, families, providers, staff, and community partners.
- Strong organizational and time management skills with the ability to manage multiple ongoing priorities independently.
- Proficiency in Microsoft Office applications, including Excel, Word, Outlook, and web-based healthcare platforms.
- Ability to communicate professionally and effectively through phone, email, written correspondence, and in-person interactions.
- Commitment to patient-centered, culturally competent, team-based care.
Work Environment & Physical Requirements
- Work is performed primarily in a clinical office environment with frequent use of computers, telephones, and office equipment.
- Requires prolonged periods of sitting with occasional standing and walking.
- Requires manual dexterity, eye-hand coordination, and the ability to operate office and clinical equipment.
- May involve exposure to communicable diseases and bodily fluids.
- Ability to manage multiple priorities and work effectively in a fast-paced healthcare environment.
- Occasional schedule flexibility may be required for meetings, educational sessions, or community events.
Reporting Structure
- Reports to: Practice Manager, Site Clinical Director, and Population Health Director
- Supervisory Responsibilities: None
Additional Requirements
- MMR and annual influenza vaccination required unless approved for medical or
religious exemption.
- PPD screening required.
- Successful completion of background screening and drug testing required.
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