Field Based RN Care Manager
APS Healthcare - Rockville, MD

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At Collaborative Health Systems, we are passionate about changing behaviors of all constituents in the healthcare system to improve health, optimize clinical quality, and reduce associated costs. Our mission is quite simply to improve the health of those we serve.

You will have an exciting opportunity to be part of the implementation and operation of Accountable Care Organizations (ACOs) aimed at increasing care coordination, improving quality of care and reducing costs for Medicare members. ACOs are designed to achieve the three part aim of better care, improved health and lower per capita costs. Improved health will be accomplished through prevention and chronic care management. The aim of the ACO is intended to reduce the trend of cost increases associated with the Medicare fee for service population.

CHS is seeking a Field Based RN Care Manager to join this new and exciting program. The RN Care Manager provides telephonic and/or on-site outreach, disease and/or case management, education and support to ACO members to support healthy lifestyle choices & to reduce long term effects of chronic illnesses. This individual performs other clinically based activities to coordinate care between the members, providers and community based health organizations. This position will be based remotely from a home office and requires travel within the Rockville region.

Essential Functions:
• Provides telephonic and/or on-site outreach, disease management and/or case management, education and other clinically based activities to plan members.
• Conducts assessments, develops treatment plans and interventions and sets goals for treatment plans/behavioral modification within the scope of license.
• Collaborates with patients medical/health and community based providers (including the PCP, HCH, certified dieticians, behavioral health specialists, or others as needed) regarding the member’s treatment needs and plan of care.
• Collects clinical data and enters information into database for tracking and metrics purposes.
• Monitors and evaluates the services and community based resources necessary to respond to the individual member’s health needs.
• Completes other special assignments and projects as assigned.

• Associate’s degree in Nursing required.
• Must have current, unrestricted RN license in the state of Maryland.
• Professional certification (CCM, CCP) preferred.

• Minimum 3 years clinical experience required.
• Previous experience in a care management, quality improvement, disease management and/or case management preferred.
• Knowledge of Medicare/Medicaid.
• An understanding of adult learning and behavior change principles preferred.
• Knowledge of community based resources.
• Strong clinical assessment skills, consistent with state licensure scope of practice requirements.
• Excellent written & verbal communication skills.
• Strong telephonic interviewing skills.
• Strong prioritization and organizational skills.
• Ability to assess patient health status, consistent with state licensure scope of practice requirements.
• Ability to integrate data and evaluate to design meaningful interventions.
• Must be able to prioritize and target interventions, consistent with state licensure scope of practice requirements designed to support long term behavioral change.

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