Title: Care Manager Type: Direct Hire; Full-time Location: Remote- residing in Alexandria, Arlington, or Springfield, VA OR Silver Spring or Wheaton, MD Shift: Monday - Friday 8AM - 5PM EST (must be flexible) Pay: $80,000 - $83,000 / year Start Date: September 20, 2021 Job Summary: The Local Care Coordinator (LCC), with the support and guidance of the CareFirst Director, Regional Care, supports the implementation of the CareFirst Patient-Centered Medical Home (PCMH) program by working with members who are attributed to a PCMH Primary Care Physician. The LCCs works with Primary Care Physicians (PCPs), Specialty Care Providers and regional support teams. The Local Care Coordinator will advocate, guide and intervene on behalf of their members to ensure successful implementation of the Care Plan while providing Complex Case Management through the duration of the Care Plan. The LCC acts as the primary interface between the CareFirst program and individual primary care providers (PCPs), Specialist and their patients (members). Essential Functions: Under the general supervision of a Director of Regional Care, the incumbent's accountabilities may include, but are not limited to, the following: * Develop and maintain strong working relationships with PCPs, Specialists and other clinicians to integrate the PCMH program into their practices. * Serves as an extension of the PCP office for PCPs who participate in the PCMH Program. * Provide on-site consultation to PCP and Care Coordination Team providers related to implementation of the PCMH model including development and documentation of Care Plans for individual members, inclusive of tracking processes, member self-management support, implementation of clinical practice guidelines and work process/patient flow improvements. Follow-up with parties as appropriate. * Collaborate with PCPs, Members and Specialty Providers in the development, documentation and implementation of Care Plans and delivery of coordinated services for members identified through this CareFirst program. * Facilitates and monitors the transition of care which involves moving the member from one healthcare practitioner and setting to another as their healthcare needs change, utilizing TCCI programs as appropriate to meet the member's needs. Implements and oversees the agreed upon plan of care in conjunction with TCCI partners and reviews all cases. Coordinates member follow-up post discharge for applicable transitions. * Maintain the electronic Care Plan. * Utilize established documentation standards to maintain quality of Care Plan documentation to include member progress toward their established state of being and barriers to achievement of Care Plan objectives/outcomes. * Develop communication and referral mechanisms to assure that there is seamless communication between PCMH, PCPs, Specialists and the Care Coordination Team. * Abides by PCMH Program Description and Guidelines. * In conjunction with Regional Care Directors and PCMH Practice Consultants, develops clinical reports for use in PCP office, facilitating PCP support of members in behavior change. * Assist the member in coordination of any additional tests, images and consults with specialists as deemed appropriate by the PCP or Specialist. For selected members with multiple prescriptions, perform a comprehensive medication reconciliation (CMR) at the onset of the Care Plan, as well as every thirty days during the life of the Care Plan, or when any medication is changed, added or deleted, assessing for efficacy and drug interaction/side effects. * Identifies appropriate TCCI program partners and other healthcare providers/vendors as well as Community Resources. Refers and follows-up on referrals and results. * Assesses the member's ongoing care needs and progress towards goals throughout the case duration and makes revisions as needed to address changes in the member's condition, lack of response to the care plan, preference changes, and transitions in care settings. Coordinates plan of care with the provider with goals of member stabilization, decreased admissions and medication management. * Direct the PCP to the Program Consultant or DIRECTOR, REGIONAL CARE when he/she identifies an opportunity for education or additional learning needs surrounding the Program that are outside of his/her understanding. * Coordinate patient education in support of standards of care guidelines and related health issues using the most appropriate modality for the member. * Facilitate the completion of member satisfaction surveys, Patient Activation Measures (PAM) and Post-PAM graduation. * Verbally or physically connect with each member every week. o Maintain member encounter rates of 100%; and o Provide effective coordination of care. * Completes mandatory training * Actively participates in team huddles and contributes to the clinical learning * Keeps current on clinical knowledge via self-directed learning * Effectively escalates issues and/or system issues to supervisor * Other duties as assigned Qualifications: * Healthcare background and current licensure as an RN is required. BSN preferred. * Minimum 3-5 years clinical experience in any of these areas: acute care, home health, physician office management, managed care organization, provider relations, pharmaceutical sales. * Demonstrates computer competencies to include word processing, spreadsheet, presentation preparation, and data base management. Demonstrated ability to learn customized computer applications. * Maximize all technology inclusive of iCentric, Skype, Microsoft Word, Microsoft Excel, Microsoft Outlook, laptop computers, iPhone, and all other relevant CareFirst unified communication technologies. * Experience with medically oriented care plan documentation. * Experience working effectively within a matrix organizational design. * Has valid driver's license and driving record showing no restrictions that would impede ability to travel by automobile. TRAVEL REQUIREMENTS: Travel Requirement: 50 - 80% (variable) by own automobile within assigned region and to attend corporate meetings throughout the Baltimore/Washington metropolitan regions. This position will be based from a home office which must satisfy all HIPAA requirements. There is no travel involved currently due to the pandemic, but there is a possibility of going back to travelling For immediate consideration, apply and call our office at (615) 435-8011. #LI-CW15 About Staffmark Staffmark is committed to providing equal employment opportunity for all persons regardless of race, color, religion (including religious dress and grooming practices), sex, sexual orientation, gender, gender identity, gender expression, age, marital status, national origin, ancestry, citizenship status, pregnancy, medical condition, genetic information, mental and physical disability, political affiliation, union membership, status as a parent, military or veteran status or other non-merit based factors. We will provide reasonable accommodations throughout the application, interviewing and employment process. If you require a reasonable accommodation, contact us. Staffmark is an E-Verify employer. 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