Travel: 25% Travel throughout our MD Market, Must be located in the DMV, MD Highly Preferred
The Maryland Primary Care Program (MDPCP AHEAD) RN Care Coordinator will work closely with Primary Care providers in the state of Maryland to identify, screen, track, monitor, and coordinate the care of patients with multiple chronic conditions to develop and deliver Comprehensive Primary Care to patients. Our Care Coordinators seek to develop, implement, and deliver extensive care coordination within our medical group and affiliated partners in a patient centered manner. They interact and collaborate with interdisciplinary care teams, population health teams, networked facility partners, physicians, and others involved in meeting the patient’s needs.
- Ensure high quality care for patients by reviewing and researching concerns or complaints and recommending corrective action as appropriate.
- Identify and recommend solutions to issues and problems.
- Maintain excellent communication and effective working relationships with patients, office managers, providers and clinical team members
- Collaborate with assigned local teams to meet Maryland Primary Care Program (MDPCP AHEAD) performance metrics
- Collaborate effectively with integrated care team to support care coordination for patients
- Review patient non-compliance reports and conduct telephonic and/or in person outreach to ensure timely disease specific and wellness visits
- Provide Transitional Care Management including, but not limited to, post in-patient and/or emergency department discharge follow up
- Provide education and assistance as it relates to lifestyle coaching, dietary improvements and plans
- Provide education and assistance in accessing the necessary care outside of the Primary Care Office
- Collaborate with providers to review high-risk patients, develop a plan of care, and administer Care Plan to patients
- As needed, meet patients in the office or community for face-to-face visits
- Provide education and assistance with patient self-management goals
- Identify and coordinate referrals to community resources, home care, and disease management programs within Privia Preferred Network
- Operate independently within defined practice(s) and patient population to achieve agreed upon goals
- Attendance and participation in regular care team meetings to discuss patient care
- Perform other duties as assigned