Care Management Nurse

We are currently in search of an experienced Care Management Nurse (Health Home) for our Brooklyn, MD location working a hybrid schedule. The Care Management Nurse at Kolmac Integrated Behavioral Health oversees the implementation of the CCG Population Health. This position is accountable for designing and maintaining systems to ensure the continuity of care between the OTP program and somatic and behavioral healthcare providers both within CCG and in the community, as well as developing processes to assist consumers in the development and maintenance of healthy lifestyles and illness management skills. 

• Schedule of Monday - Friday 5am - 1pm
• Acts as a comprehensive care coordinator for participants assigned to care, assessing their needs accordingly and facilitating communication amongst other clinicians providing care
• Leads practice transformation based on Population Health principles and state/accrediting body requirements
• With agency leadership, acts as a "champion" for the Population Health philosophy and provides education to staff
• Develops and maintains working relationships with primary and specialty care providers including inpatient facilities and emergency departments
• Monitors Population Health performance at the population and participant level and implements improvement efforts via statistical data gathering
• Designs and develops prevention and wellness initiatives
• Establishes the effective use of patient registries (CRISP and eMedicaid) as applicable to manage specific patient populations and to improve disease and population health outcome measures
• Collaborates/consults with specialty practices to identify data needs related to care coordination
• Monitors participants' monthly visits to assure the appropriate population home are delivered
• Oversees the entering of all required data
• Performs comprehensive assessments of physical, emotional, psychosocial and environmental needs of participants and develop care plans for all assigned Population Health enrollees around physical health or social goals
• Facilitates health education groups
• Assesses, coordinates and implements service planning needs of assigned persons
• Evaluates/assists in evaluation of appropriateness of plan of care and revises on an ongoing basis with communication to all other disciplines
• Reviews results of laboratory tests and other diagnostic procedures and reports to the nurse practitioner or psychiatrist
• Identifies significant clinical findings, makes conclusions and intervenes appropriately under the direction of the nurse practitioner consultant
• Compares ongoing outcome data to baseline data to monitor clients
• Initiates client education based on identified learning needs of the client and/or those providing care and documents appropriately
• Supports and monitors compliance of the individual including checking of prescription labels and storage
• Consults with behavioral health staff about participants' identified health conditions
• Attends treatment team meetings with behavioral health staff to plan and coordinate care
• Assists in contacting medical providers & hospitals for coordination of care efforts
• Provides training on medical diseases, treatments, & medications to health home participants
• Assists in the training and education of OTP staff regarding population health services
• Provides training on medical diseases, treatments, & medications to behavioral health staff, as indicated
• Takes action to correct observed risks to patient safety
• Reports adverse events and near misses to supervisor
• Implements policies, procedure, and standards consistently in the performance of assigned duties
• Develops effective working relationships and maintains good communication with other team members. Identifies possible risks in processes, procedures, devices and communicates the same to those in charge
• Other duties as assigned

• Three plus years’ experience in a medical office setting, hospital, or similar patient customer service environment. Five plus years, preferred
• Licensure as a Registered Nurse in the state of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, is required
• Demonstrated success in exhibiting teaching, coaching, and development skills
• Demonstrated effectiveness in a consultative role, and experience leading complex change
• Ability to create a motivating environment for clinical and professional personnel
• Highly effective interpersonal, verbal, and written communication and presentation skills. The successful
• Demonstrate effectiveness in education others on a broad spectrum of health issues
• Demonstrate ability to collaborate with a multidisciplinary treatment team
• Strong sense of teamwork and collaboration, as caseload coverage is shared amongst the entire Population Health Nurse Care team and all aspects of services are further coordinated with several multi-disciplinary teams
• Knowledge of the Maryland healthcare industry and policy preferred
• Ability to conduct online research to source information and resources for clients preferred
• Knowledge of area resources and case management preferred
• Ability to analyze and conceptualize data to ensure achievement of desired outcomes
• Technically proficient in Microsoft Office programs and database use. Ability to learn and use an electronic medical record and health information exchange to enter clinical information and run reports