RN CTO Lead Care Manager

General Summary of Position

Serves as a member of the interdisciplinary care management team, providing care coordination for Medicare fee-for-service beneficiaries attributed to CTO-supported practices. Responsible for care management and coordination for assigned Medicare beneficiaries and serves as the liaison between the medical practice(s) and the CTO care team. This position supports the Union Memorial Adult Medicine Center and the Kirk Avenue practice. CCM certification required.

Primary Duties and Responsibilities

• Contributes to departmental goals and complies with all policies, procedures, quality, safety, and regulatory standards.

• Serves as the care coordination lead for a panel of attributed Medicare beneficiaries in collaboration with the interdisciplinary team.

• Ensures timely access to care, post-discharge follow-up, and use of alternative visit options (phone, e-visits, group, home, and community-based visits).

• Assists with appointment scheduling, including annual wellness visits.

• Ensures follow-up within two days of hospital discharge and within one week of Emergency Department visits.

• Coordinates referrals to high-volume and high-cost specialists, hospitals, and emergency services.

• Connects patients to behavioral health and community resources and supports advance care planning and PFAC participation.

• Provides direct patient care under physician direction, including wellness visits, transitional care, vaccinations, and screenings.

• Manages a caseload in accordance with MD Primary Care Program (MDPCP) standards, including assessments, care planning, and outcome monitoring.

• Conducts comprehensive assessments and interventions for high-acuity patients.

• Evaluates and adjusts care plans to promote quality, cost-effective care.

• Acts as a patient and family advocate and liaison among physicians, facilities, and community partners.

• Provides clinical guidance to care team members to support effective care delivery.

• Maintains regular patient and provider communication to close gaps in care, support preventive services, and promote engagement using available data tools.

• Facilitates team communication through huddles, meetings, conference calls, and written updates.

• Analyzes patient data and presents actionable insights to support care coordination and quality improvement.

• Participates in quality improvement initiatives, committees, and community outreach as assigned.

• Performs other duties as assigned.

Minimal Qualifications
Education

• Associate's degree in Nursing (ADN) required and
• Bachelor's degree in Nursing (BSN) preferred

Experience

• 3-4 years Work experience including 1 or more years of proven case management experience. Familiarity with the local area and/or population health workforce integration. required and
• Experience with data collection and reporting; community outreach experience, working in an ambulatory setting preferred

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure Registered Nurse licensed in the State of Maryland Upon Hire required and
• CCM - Certified Case Manager from a nationally recognized certification agency within 1-1/2 Yrs preferred and
• DL NUMBER - Driver License Valid and in State (DRLIC) Upon Hire required

Knowledge Skills and Abilities

• Effective verbal and written communication skills.
• Excellent interpersonal and customer service skills especially serving geriatric patients.
• Strong analytical and critical thinking skills.
• Strong community engagement and facilitation skills.
• Advanced project management skills.
• Commitment to collective impact concepts.
• Flexibility and the ability to work autonomously as well as take direction as needed.
• Cultural competency.
• Proficient computer skills along with experience using Microsoft applications-Word Excel etc. and familiarity with entering data in an electronic medical record (EMR).

• Other