Title/Position: Maryland Primary Care Program Nurse Care Coordinator

Department or Business Unit: Population Health, Mid Atlantic

Reporting Structure: MDPCP Program Clinical Lead

Employment Type: FTE

Exemption Status: Exempt

Min. Experience: Mid-Level

Travel Required: Yes, local travel 

Overview of the Role:

The Maryland Primary Care Program (MDPCP) Care Coordinator will work closely with Primary Care providers in the state of Maryland to identify, screen, track, monitor, and coordinate the care of patients with multiple chronic conditions to develop and deliver Comprehensive Primary Care to patients. Our Care Coordinators seek to develop, implement, and deliver extensive care coordination within our medical group and affiliated partners in a patient centered manner. They interact and collaborate with interdisciplinary care teams, population health teams, networked facility partners, physicians, and others involved in meeting the patient’s needs

Primary Job Duties: 

• Collaborate with assigned local teams to meet Maryland Primary Care Program performance metrics
• Own the execution and performance toward defined performance metrics
• Collaborate effectively with integrated care team to support care coordination for patients
• Review patient non-compliance reports and conduct telephonic and/or in person outreach to ensure timely disease specific and wellness visits
• Independently conduct Annual Wellness Visits as needed
• Provide Transitional Care Management including, but not limited to, post in-patient and/or emergency department discharge follow up
• Provide education and assistance in accessing the necessary care outside of the Primary Care Office
• Collaborate with providers to review high-risk patients, develop a plan of care, and administer Care Plan to patients
• As needed, meet patients in the office or community for face-to-face visits
• Provide education and assistance with patient self-management goals
• Identify and coordinate referrals to community resources, home care, and disease management programs within Privia Preferred Network
• Operate independently within defined practice(s) and patient population to achieve agreed upon goals
• Attendance and participation in regular care team meetings to discuss patient care
• Perform other duties as assigned

Minimum Qualifications:

• 2-5 years of population health or care coordination experience
• RN or LPN clinical certification and/or experience
• Active unrestricted license in MD or able to obtain (if needed)
• Strong computer and EHR skills and expertise 
• Preferred experience with Medicare aged patients in a value-based program 
• Preferred experience educating and engaging patients 
• Experience working in an outpatient medical office 
• Ability to travel to and from care centers to meet with patients and providers
• Must comply with all HIPAA rules and regulations

Interpersonal Skills & Attributes:

• Great communicator - creates clarity and adjusts style to expertise of audience
• Comfortable in a fast-paced environment and with ambiguity 
• Highly collaborative and effective across an organization and region amongst multiple stakeholders
• Performance Driven – knows the team’s goals and how to prioritize personal and daily activities to meet those metrics
• Team focused: understands the need to work as a group to achieve goals, support team members, and listen to other points of view
• Demonstrates sound judgment 
• Ability to function independently efficiently and meet defined goals
• Must be detail-oriented and possess critical thinking skills
• Possess a focused work ethic and a high level of professionalism

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

Privia Health is committed to providing equal employment opportunity to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, Privia will provide reasonable accommodations for qualified individuals with disabilities. Privia's goal is for our people to reflect the communities that we serve and to increase representation of women, people of color, veterans and individuals with disabilities in our organization.

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Employee Signature: Date: