Posted in Other about 5 hours ago.
Location: Bel Air, Maryland
Job Description
JOB SUMMARY: This role coordinates care of the Care Transformation Organization (CTO) assigned Medicare patients within the primary care provider's office. Works with an interdisciplinary team to manage care and coordinate care services attributed to partisan practices. Assess psychosocial needs and functional deficits of the patient and informs providers of changes in the care plan and/or patient's condition. Through an integrated approach, this role completes intake assessments, assists with the treatment planning, monitors patient progress, facilitates patient and family meetings, and coordinating and implementing of treatment referrals. This position plans and organizes community-based services that support the patients' self-management, adherence to treatment plans, and reduction of unnecessary re-hospitalization.
Care coordination:
* Assess psychosocial needs and functional deficits of patients
* Provide telephonic guidance, advice and support to patients
* Set health improvement / health management goals for patients
* Facilitate and coordinate care from within and outside of the practice
* Develop and maintain electronic care plan
2. Communicate with patients' primary care provider (physician or nurse
practitioner) regarding changes in patient status and/or care plan.
3. Utilize electronic medical record to document in an accurate, thorough, and
timely fashion.
4. Participate in team-based care. Willingly accept direction from providers and
serve as a clinical resource to medical assistants and other practice team
members. Communicate proactively.
5. Provide clinical coverage in the practice, as needed. Availability for practice
patients with acute care needs (especially if providers are not immediately
accessible).
6. Participate in educational programs and inservices supporting quality
improvement and clinical efficiency initiatives.
7. Serve as a resource for patients requiring special assistance (i.e. post-discharge
medication reconciliation) and/or short-term follow-up care (i.e. blood pressure
checks).
8. Leads by example; maintains high personal standards for customer satisfaction,
productivity, learning, cooperation, responsiveness; and optimism.
9. Establish an effective and appropriate means of communicating and collaborating
with providers, team members, payers and ancillary services to ensure safe and
efficient services.
10. Demonstrates professionalism; competence; and open communication style; high
integrity; energy, creativity, diplomacy; and flexibility.
11. Assists with other duties and special projects, as assigned.
Company Description
University of Maryland Upper Chesapeake Health (UM UCH) offers the residents of northeastern Maryland an unparalleled combination of clinical expertise, leading-edge technology, and an exceptional patient experience.
A community-based, integrated, non-profit health system, our vision is to become the preferred, integrated health system creating the healthiest community in Maryland. We are dedicated to maintaining and improving the health of the people in our community through an integrated health delivery system that provides high quality care to all. Our commitment to service excellence is evident through a broad range of health care services, technologies and facilities. We work collaboratively with our community and other health organizations to serve as a resource for health promotion and education.
Today, UM UCH is the leading health care system and second largest private employer in Harford County. Our 3,500 team members and over 650 medical staff physicians serve residents of Harford County, eastern Baltimore County, and western Cecil County.
University of Maryland Upper Chesapeake Health owns and operates:
University of Maryland Harford Memorial Hospital (UM HMH), Havre de Grace, MD
University of Maryland Upper Chesapeake Medical Center (UM UCMC), Bel Air, MD
The Upper Chesapeake Health Foundation, Bel Air, MD
The Patricia D. and M. Scot Kaufman Cancer Center, Bel Air, MD
The Senator Bob Hooper House, Forest Hill, MD
Qualifications
Education & Training: Current Maryland RN license required. Completion of a Bachelor's of Science degree in nursing preferred. BLS required. Work Orientation & Experience: Three (3) years nursing care experience required. Experience in case management and/or utilization management and ED or outpatient medical practice preferred. Basic computer skills required
Additional Information
All your information will be kept confidential according to EEO guidelines.
Compensation:
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University of Maryland Medical System
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University of Maryland Medical System
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