Registered Nurse Case Manager (Rn) - Population Health

Experience the highest level of appreciation at UM Baltimore Washington Medical Center — named Top Workplace in the Baltimore area by The Baltimore Sun two years in a row (2019 & 2020); Top Workplace in the USA for 2021! As part of the acclaimed University of Maryland Medical System, our facility is one of three ANCC Pathway to Excellence® designated hospitals in Maryland. UM BWMC features one of the state’s busiest emergency departments, as well as a team of experts who care for our community and one another. The University of Maryland Baltimore Washington Medical Center (UMBWMC) provides the highest quality health care services to the communities we serve. Our medical center is home to leading-edge technology, nationally recognized quality, personalized service and outstanding people. We have 285 licensed beds and we’re home to 3,200 employees and over 800 physicians. Our expert physicians and experienced, compassionate staff are connected to medical practices in the local community as well as at University of Maryland Medical Center in downtown Baltimore. For patients, this means access to high-quality care and research discoveries aimed at improving Maryland’s health. Our physicians and nursing staff specialize in emergency, acute, medical-surgical and critical care. In addition, our medical center is home to many Centers of Excellence, offering expert outpatient health care.

Shift Schedule: Monday - Friday 8:00AM - 4:30PM

General Summary

Under the general supervision, provides care coordination, clinical utilization management and discharge planning for an assigned case load. This role is patient focused, outcome oriented and based on general and specialty professional standards and functions within an interdisciplinary practice model. This role is accountable for the continuity and integration of patient care services.

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. These are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

• Coaches the patient and /or family on how to respond to acute and or worsening symptoms in order to avoid unnecessary hospitalizations. Educates patients and/or family on the availability of same day appointments.
• Works with care team to achieve and maintain PCMH recognition as it relates to care coordination for the patients. Responsible for submitting timely quality measures for PCMH recognition.
• Identifies self-management resources including health education classes and support groups to achieve care plan goals.
• Provides the patient and/or family education about relevant disease and their management, including medication management.
  • Identifies self-management resources including health education classes and support groups to achieve care plan goals.
  • Coaches the patient and /or family on how to respond to acute and or worsening symptoms in order to avoid unnecessary hospitalizations. Educates patients and/or family on the availability of same day appointments.
• Collaborates with the interdisciplinary team to identify patients most likely to benefit from care coordination services.
• Takes the lead in ensuring the continuity and consistency of care which extends beyond practice boundaries. Serves as a liaison to acute care hospitals and post-acute services to facilitate comprehensive discharge planning and follow- up care.
• Assesses the patient’s risk factors and needs for care coordination, clinical utilization management services, discharge planning and identifies appropriate preventative services.
• Models' effective customer service behaviors. Identifies and acts on opportunities to understand and respond to customers.
• Contributes to problem solving within the team through communication, collaboration, data collection, obtaining consensus and evaluating outcomes of treatment options. Tracks patients’ progress towards care plan goals and revises the care plan as indicated.
• Develops a care plan and treatment goals with the patient and/or family.
• Develops effective working relationships with physicians, nurse practitioners, nurses, allied health professionals (e.g. social workers, psychologists, etc.), medical assistants and referral coordinators.
• Assists with the maintenance of patient registries to manage specific patient populations and improve disease outcome measures. Assists with the implementation of clinical decision support tools, referral and test tracking and preventive medicine reminders.
• As part of the interdisciplinary team lead by the Primary Care Provider, the case manager has an integral role in the continuity and integration of patient care services.
  • Collaborates with the interdisciplinary team to identify patients most likely to benefit from care coordination services.
  • Assesses the patient’s risk factors and needs for care coordination, clinical utilization management services, discharge planning and identifies appropriate preventative services.
  • Develops a care plan and treatment goals with the patient and/or family.

Education and Experience

• Licensure as a Registered Nurse in the state of Maryland, or eligible to practice due to Compact state agreements outlined through the Maryland Board of Nursing, is required.
• Three (3) years of Clinical nursing experience required.
• Graduation from an accredited school of nursing is required: a Bachelor’s degree is preferred.