Director of Care Coordination and Management
Care. Compassion. Community.
Adventist HealthCare (AHC), based in Rockville, Maryland, is a faith-based, not-for-profit organization of dedicated professionals who work together each day to provide excellent wellness, disease management and health-care services to the community. Adventist was founded upon the principle of wellness more than 100 years ago and today provides innovative care to heart attack victims, cancer patients and premature babies and the community.
AHC*s integrated, health-care delivery network includes four nationally accredited acute care and specialty hospitals, mental health services and home health agencies serving the Washington, D.C. metropolitan area. Each year, Adventist provides high quality, compassionate care for more than 450,000 men, women and children in the community through its nearly 5,500 employees, 2,000 physicians and almost 1,200 volunteers.
The role directly supports AHC's strategic objectives of extending God's care by delivering care management services, integrating with physicians, and improving the overall quality of health care delivered in the communities we serve. The role is responsible for the development and management of the cross-continuum care management program. Works collaboratively with hospital staff and the clinical integration teams across the entities, physicians, and their staff to help coordinate care to ensure effective and efficient delivery of services and to improve patient outcomes and reduce health care costs. Works in coordination with appropriate stakeholders to direct and manage Care Coordination and Management activities in the following settings:
Adventist Medical Group
One Health Quality Alliance
Patients Discharged to Home from AHC Facilities
Patients discharged to Home from partner SNFs
Additional settings, as developed
Assist with identifying patients appropriate for care management interventions based on specific criteria set forth by the clinical team
Coordinate Care Management activities across Adventist Healthcare
Develop and manage Care Coordination activities for One Health Quality Alliance and other programs as appropriate
Participate in Strategic Development and Planning, as needed for Population Health Management
Meet with outpatient physicians and office staff regarding patient care management program
Provide oversight and assist with care plan development and implementation by care team
Review patient needs to assure care team is anticipating and meeting medical, behavioral, and social needs of the patient
Assist care team in linking patients with community services
Ensure all patients receiving care management services receive medication reconciliation
Facilitate patient transitions of care
Help patients and their families identify barriers to health care
Understand patient literacy and cultural needs and address to improve health outcomes
Assure optimal communication between PCPs and care managers. Work with members of care team to resolve any communication barriers/issues
Maintain patient documentation
Compile data to support program hiring, training and management of appropriate Care Coordination and Management staff
Work collaboratively across all AHC entities and service areas
Represent Adventist Healthcare with appropriate external entities such as Nexus Montgomery
Act as AHC*s liaison with Designated Community and Government Organizations
Registered Nurse, Masters in Social Work, or Bachelors in Social Work with at least two years of experience in a related field
Masters Degree in Population Health or Public Health preferred
5-7 years in a managed care environment
Track record of strong clinical utilization and care management
Experience identifying best practices for population health tactics and programs
Strong leadership skills
Experience managing a minimum of 5 staff
Excellent time management and prioritization skills to focus on multiple projects simultaneously and adapt to change
Excellent oral and written communication skills
Strong personal computer skills, including working knowledge of Microsoft Office suite
Tobacco use is a well-recognized preventable cause of death in the United States and an important public health issue. In order to promote and maintain a healthy work environment, We will not hire applicants for employment who either state that they are nicotine users or who test positive for nicotine use.
We will withdraw offers of employment to applicants who test positive for Cotinine (nicotine). Those testing positive for cotinine are given the opportunity to re-apply in 90 days, if they can truthfully attest that they have not used any nicotine products in the past ninety (90) days and successfully pass follow-up testing.
Equal Employment Opportunity
We are an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected veteran status.