+ JOB DESCRIPTION DETAILS + Job Summary : + Under the guidance of the CalvertHealth Medical Group (CHMG) practitioners, the Care Manager (CM) oversees a panel of patients identified as ‘complex’ and/or requiring longitudinal care management services, based on clinical team referral. This includes monthly in person or virtual outreach to patients to manage condition(s) and effectively connect patient with resources. The Care Manager also drives safe clinical transitions for the patients from acute and outpatient settings. Position will leverage appropriate resources, follow best practice guidelines for medically complex patients, and serve as a conduit for communication, collaboration, and coordination. The Care Manager will work collaboratively with CHMG and CalvertHealth Medical Center (CHMC), as well as other hospital location, care management teams to ensure safe and seamless transitions of care for the complex patient. This will be achieved through the application of clinical nursing skills, knowledge of standards of patient care, clinical and educational consultation. + The Care Manager serves as liaison between hospitalist, patient, primary care provider, and other care partners and is responsible for proactively coordinating and assisting appropriate follow-up with patients transitioning from the hospital to home or during other transitions of care. In collaboration with the clinical practitioners, hospital care teams and family/significant others, the Care Manager will work with the medically complex and high risk patients to optimize recommendations to ensure continued health with the goal of preventing readmission. + The Care Manager may collaborate with the CHMG provider and clinical staff and engage with patients through preventative healthcare by coordinating, performing and completing or supporting the Welcome to Medicare (WTM) and Annual Wellness Visit (AWV) to a specified panel of Medicare (or Medicare eligible) patients. This activity may be performed in collaboration with providers and office staff to achieve visit goals each year. + Position requires travel to CHMG primary care practice locations and will require a hybrid schedule depending on provider and location preferences. + Education : + Nursing degree: BSN/MSN is preferred. + Registration/Certification/Licensure : + Current Maryland Registered Nurse license + Unexpired driver’s license + Basic Life Support certification required + Experience : + RN with a minimum 5 years of clinical experience in both inpatient and ambulatory care settings preferred. + Case Management and Chronic Care Management experience preferred and desirable. + Proficient in Microsoft Office products, Meditech software experience preferred. + Other Requirements : + Maintains unit-specific and hospital competencies, mandatory learning, and any clinical certifications required in accordance with the Staff Education and Training policy GA-057 and/or any other department requirements. + Possess exceptional communication and customer service skills with the ability to relate to diverse populations of public and patients, regardless of ethnic, religious and economic status. + Possess exceptional independent, critical thinking skills with the ability to identify issues, collect and analyze data, establish facts, draw valid conclusions, make recommendations, and implement effective action plans to solve problems. + Possess excellent written, oral, and active listening skills with the ability to give full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times; able to listen to and understand information and ideas presented through spoken words and sentences. Possess excellent clinical record documentation skills. + Possess strong time management skills with the ability to properly prioritize, manage and complete simultaneous tasks with frequent interruptions while paying close attention to the details. + Ability to work in a fast-paced environment with a variety of personalities and work styles. + Possess a high degree of empathy, ethics, initiative, and judgment with the ability to maintain confidence relating to sensitive matters. + Maintain a strong professional relationship with community, social service, and health resources. + Possess the ability to motivate patients and families to participate in their care and maintain adherence to their care plan. + Ability to function autonomously while keeping team members and leaders informed. Ability to make independent decisions in compliance with CalvertHealth policies and procedures. + Maintain integrity, honesty and accuracy in the representation of CalvertHealth while adhering to all Federal, State and company guidelines. + Ability to drive as a routine part of duties