CTO Lead Care Manager RN

About this Job

The CTO Lead Care Manager is a highly experienced, confident nursing professional responsible for leading complex, high-volume care management within a busy primary care practice serving approximately 2,000 patients. This role requires advanced clinical judgment, strong autonomy, and the ability to manage chronic and acute care transitions while partnering closely with an LPN and other interdisciplinary teams to deliver coordinated, patient-centered care.

This is a 100% in-person position, Monday–Friday, 8:00 a.m.–4:30 p.m., with flexibility around start time based on discussion. The Lead Care Manager has a dedicated private office and workspace and functions as a clinical mentor within the practice.

• Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.
• In collaboration with the interdisciplinary care team acts as primary care team agent for the coordination of care for a panel of attributed Medicare beneficiaries by ensuring the following:
  Ensures attributed beneficiaries have timely access to care (same day or next day access to the patient's own practitioner and / or care team for urgent care or transition management);
  Facilitates use of alternatives for care outside of the traditional office visit to increase access to the care team and the practitioner such as e-visits phone visits group visits home visits and visits in alternate locations (senior centers assisted living) captured in the medical record;
  Assists patients with scheduling appointments with providers including annual wellness visits.
• Attributed beneficiaries receive a follow up interaction from the practice within 2 days for hospital discharge and within one week for Emergency Department (ED) discharges;
  Coordinates referral management for attributed beneficiaries seeking care from high-volume and / or high-cost specialists as well as EDs and hospitals;
  Facilitates connection to services for patients who may benefit from behavioral health services including : patients with serious mental illness patients with substance use disorders' patients with depression anxiety or other mental health conditions patients with behavioral and social risk factors and BH issues patients with multiple co-morbidities and BH issues;
  Assists with identifying patients to participate in the Patient-Family / Caregiver Advisory Council (PFAC) and help to organize and facilitate the PFAC annual meetings;
  Engages attributed beneficiaries and caregivers in a collaborative process for advance care planning (MOLST Advanced Directives Proxy).
• Under the direction of the practice physician may perform direct patient care including wellness visits transitional care administer vaccinations screenings etc.
• Assesses plans implements monitors and evaluates options and services to meet health needs of attributed beneficiaries. Manages a caseload in compliance with contractual obligations and the MD Primary Care Program (MDPCP) standards.
• Conducts comprehensive member assessments through root cause analysis based on member's needs and performs clinical intervention through the development of a care management treatment plan specific to each member with high level acuity needs.
• Monitors and evaluates effectiveness of care plan and modifies plan as needed. Supports member access to appropriate quality and cost-effective care. Coordinates with internal and external resources to meet identified needs of the member's care plan and collaborates with providers.
• Acts as a liaison and member advocate between the member / family physician and facilities / agencies. Provides clinical consultation to physicians professional staff and other teams members / supervisors to provide optimal quality patient care and effective operations.
• Interacts continuously with members family physician(s) and other resources to determine appropriate behavioral action needed to address medical needs. Reviews benefits options researches community resources trains / creates behavioral…