Physician Enterprise - Practice Solutions Jobs

Position Objective: Endowed with clinical knowledge and experience, the Maryland Primary Care Program (MDPCP) Community Care Manager- SW works collaboratively with physicians, staff, and other health care professionals to provide care coordination and ensure that safety, best practices, and high quality standards are maintained across the continuum. S/he maintains knowledge of care management, behavioral health, social determinants of health, and chronic disease self-management resources available to patients and facilitates patients’ adoption of supportive services. S/he plays an integral role in promoting access to appropriate community care resources, including transitional care services for vulnerable patients recently discharged from the hospital or ED, and providing care management to high-risk patients. S/he maintains access to and proficiency in programs including Epic, patient registries, and CRISP. Success will be measured by performance results at the practice and population levels. Essential Job Duties: Function as team subject matter expert in identifying the social determinants of heath and the optimal community resources to support high and rising risk patients in the self-care management. Assist patients through healthcare continuum as a patient advocate, navigator, and liaison to team, providers and/or community resources. Provide leadership to the team to improve care, community resource coordination, and manage the referral processes. Facilitate health and disease patient education and support patient self-management of disease and behavior modification interventions. Collaborate with patients, care team, and providers to understand patient short and long-term goals and contribute to patient longitudinal plan of care. Coordinate continuity of patient care with providers across the healthcare system, including post-hospital or ED discharge. Use high-risk screening criteria to identify and manage high-risk patients, including patients with multiple comorbidities or are at risk of avoidable utilization/ readmission. Participate on teams for data collection, health outcomes reporting, clinical audits, and programmatic evaluations related to the Maryland Primary Care Program (MDPCP), and quality improvement initiatives. Evaluate the psycho-social clinical plan of care, resource utilization, and contribute to the development of new tools, forms, and procedures. Contribute to the performance evaluation of team members. Educational/Experience Requirements: Master’s degree with a focus in social work. LCSW – C required (or obtained within 6 months of employment) At least 5 years of experience in healthcare with care management experience. Required License/Certifications: Required License/Certification: Licensed Certified Social Worker (LCSW) or Licensed Certified Social Worker Clinical (LCSW-C) from the Maryland Board of Social Work Examiners or other approved designated Social Worker license/certification. If Licensed Certified Social Worker (LCSW) must obtain Licensed Certified Social Worker Clinical (LCSW-C) within 6 months of hire. Current American Health Association Health Care Provider Basic Life Support (BLS) CPR certification. Case Management Certification strongly preferred Working Conditions, Equipment, Physical Demands: There is a reasonable expectation that employees in this position will not be exposed to blood-borne pathogens. Physical Demands – Light Duty The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act. The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary. Luminis Health Benefits Overview: • Medical, Dental, and Vision Insurance • Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year) • Paid Time Off • Tuition Assistance Benefits • Employee Referral Bonus Program • Paid Holidays, Disability, and Life/AD&D for full-time employees • Wellness Programs • Employee Assistance Programs and more *Benefit offerings based on employment status Pay Range $33.55 — $50.33 USD Luminis Health Benefits Overview: • Medical, Dental, and Vision Insurance • Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year) • Paid Time Off • Tuition Assistance Benefits • Employee Referral Bonus Program • Paid Holidays, Disability, and Life/AD&D for full-time employees • Wellness Programs • Employee Assistance Programs and more *Benefit offerings based on employment status Opt-in for text notifications! Luminis Health's two-way SMS texting platform lets you receive notifications and messages from our Talent Acquisition team directly on your phone. To enable this feature, select "yes" when asked to "opt-in to receive text messages" and to "Receive updates from a recruiter about this job via SMS" when completing your application. Once you are opted in, you can easily opt-out at any time. Standard text messaging rates may apply based on the candidate's mobile carrier plan. Luminis Health is not responsible for any charges incurred by the recipient. Candidates are encouraged to review their mobile carrier's plan for applicable text messaging rates and usage charges.

Position Objective: Advanced Medical Assistant The Advanced Medical Assistant is an essential part of the Advanced Primary Care Team and facilitates meeting the goals of the Maryland Primary Care Program and Value Based Contracts. Their main responsibilities are to coordinate patient care, provide patient outreach and education and identify barriers that may affect the patient from meeting his/her treatment goals. The Advanced Medical Assistant will perform a variety of administrative and clinical tasks to support the provider/practice to ensure the patient receives the right care at the right time and right place to decrease hospital re-admission and unnecessary utilization of Emergency Room and/or Urgent Care. The Advanced Medical Assistant maintains knowledge of care coordination/management, behavioral health resources, CRISP Portal/Reports, Value Based Contract Portals, EPIC Registries and patient self-management tools/resources. Essential Job Duties: Monitor and validate patient attribution to the practice and the care teams within the practice (known as empanelment). Ensure patients identified as increased risk receive targeted, proactive, relationship-based (longitudinal) care coordination and/or care management. Pre-visit planning workflow for Annual Wellness Visits scheduled with the LPN Team and/or practice provider. Provide patient education and resources to engage the patient in his/her treatment plan and improve their overall health. Actively manages assigned panel of to develop relationship with patient as an integral member of team, provide follow-up contact with patient as indicated to ensure compliance with recommendations medications, lab/x-ray, specialist visits, PCP visits, dieticians, CDE, etc. Maintains access to all Value Based Payor portals for attestation of metrics and/or to pull appropriate care gap and utilization reports. Provides patient outreach for TCM/ED visits within required timeframe, i.e. within 48 hours inpatient discharge; within 7 days emergency room discharge. The Advanced Medical Assistant will schedule a follow up appointment with the patients primary care provider or Advanced Internal Medicine. Assist patients in setting SMART goals for self -management, teaching them how to do self-management tasks and report abnormal findings to their provider team; Assess barriers when patient has not met treatments goals, is not following treatment plan of care, or has not kept important appointments; refers patient to the Community Care Management Team (RN, LCSW, CHW) for intervention. Identify patient social and behavioral health needs, consult with clinician, as appropriate provide warm hand off to Ambulatory Care Management, social work, care navigation, and behavioral health services. Collaborate with providers, and other frequently used healthcare resources to develop effective timely communication between the patients care teams; and in assessing the patients progress toward individual health care goals Oversees the development, procurement, and adoption of patient self-management educational resources used by the primary clinical teams. Ensure targeted patients who have received follow-up after ED, hospital discharge, or other triggering events receive short-term (episodic) care management if applicable. Contribute to a positive experience for patients and families through courteous telephone interactions and interview activities, accurate and expeditious routing, as well as referral to appropriate clinical staff when necessary. Recognize and report data inconsistencies to appropriate practice personnel, and facilitate appropriate data capture and reporting methodologies Contribute to teamwork within and between departments. Regularly participate in meetings as deemed appropriate by leadership. Provide and receive constructive ideas, suggestions and feedback in a positive manner. Work collaboratively with co-workers to effectively resolve issues that impact departmental operations. Monitor and collaborate with practice to improve performance on key outcomes, including cost of care, electronic clinical quality measures, beneficiary experience, and utilization measures. Educational/Experience Requirements: The minimum level of education and experience for this position includes: Minimum of High School Diploma Completion of accredited medical assistant training program preferred. Three years of experience as a Medical Assistant Experience with Microsoft Office and Excel. Strong customer service skills Basic math skills. Required License/Certifications: CMA, RMA or AAMA (through an approved/accredited organization). Must maintain Certification or credentials while employed required within 6 months of hire. CPR Certified Working Conditions, Equipment, Physical Demands: There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens. Physical Demands –Light Work The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act. The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary Updated: 2.5.24 Pay Range $20 — $26.78 USD Luminis Health Benefits Overview: • Medical, Dental, and Vision Insurance • Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year) • Paid Time Off • Tuition Assistance Benefits • Employee Referral Bonus Program • Paid Holidays, Disability, and Life/AD&D for full-time employees • Wellness Programs • Employee Assistance Programs and more *Benefit offerings based on employment status Opt-in for text notifications! Luminis Health's two-way SMS texting platform lets you receive notifications and messages from our Talent Acquisition team directly on your phone. To enable this feature, select "yes" when asked to "opt-in to receive text messages" and to "Receive updates from a recruiter about this job via SMS" when completing your application. Once you are opted in, you can easily opt-out at any time. Standard text messaging rates may apply based on the candidate's mobile carrier plan. Luminis Health is not responsible for any charges incurred by the recipient. Candidates are encouraged to review their mobile carrier's plan for applicable text messaging rates and usage charges.