Job Description

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

Qualifications

• Must have Active RN License

• 2+ years of population health or care coordination experience

• Strong computer and EHR skills and expertise

• Preferred experience with Medicaid patients in a value-based program

• Preferred experience educating and engaging patients

• Experience working in an outpatient medical office

• Ability to travel to and from care centers to meet with patients and providers

• Must comply with all HIPAA rules and regulations

• Bilingual candidates are encouraged to apply (especially those who speak Spanish)

The salary range for this role is $75,000.00 to $85,000.00 in base pay and exclusive of any bonuses or benefits (medical, dental, vision, life, and pet insurance, 401K, paid time off, and other wellness programs) . This role is also eligible for an annual bonus targeted at 10%. The base pay offered will be determined based on relevant factors such as experience, education, and geographic location

Additional Information

All your information will be kept confidential according to EEO guidelines.

**Technical Requirements (for remote workers only, not applicable for onsite/in office work):**

In order to successfully work remotely, supporting our patients and providers, we require a minimum of 5 MBPS for Download Speed and 3 MBPS for the Upload Speed. This should be acquired prior to the start of your employment. The best measure of your internet speed is to use online speed tests likehttps://www.speedtest.net/. This gives you an update as to how fast data transfer is with your internet connection and if it meets the minimum speed requirements. Work with your internet provider if you have questions about your connection. Employees who regularly work from home offices are eligible for expense reimbursement to offset this cost.

Privia Health is committed to creating and fostering a work environment that allows and encourages you to bring your whole self to work. We understand that healthcare is local and we are better when our people are a reflection of the communities that we serve. Our goal is to encourage people to pursue all opportunities regardless of their age, color, national origin, physical or mental (dis)ability, race, religion, gender, sex, gender identity and/or expression, marital status, veteran status, or any other characteristic protected by federal, state or local law.