MedStar Health · 11 hours ago
CTO Lead Care Manager RN
Rosedale, MD
Full-time
Onsite
Mid, Senior Level
3+ years expMedStar Health is seeking a highly experienced CTO Lead Care Manager RN to lead complex care management within a primary care practice serving approximately 2,000 patients. The role involves coordinating care for Medicare beneficiaries, conducting comprehensive assessments, and collaborating with interdisciplinary teams to deliver patient-centered care.
Health CareMedical
Responsibilities
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 routines and enables members to be active participants in their own healthcare
Ensures members are engaging with their PCP to complete their care management treatment plan or preventive care services
Ensures daily telephonic patient communication to help to close gaps in care and provide up-to-date healthcare information helping to facilitate the members understanding of his/her health status using available reports including quality m page and HIE CRISP to ensure relevant medical history/encounter are accessible in EMR
Facilitates ongoing communication amongst practice and care team by participating in huddles hosting regular conference calls in-person meetings or coordinating regular email updates to ensure alignment of activity discuss new developments and exchange information
Performs analysis of attributed beneficiary data and presents data intelligently and creatively in a way that can be easily and quickly grasped by the practice and interdisciplinary care team as appropriate
Participates in multidisciplinary quality and service improvement teams as appropriate. Participates in meetings serves on committees and represents the department and hospital/facility in community outreach efforts as appropriate
Performs other duties as assigned
Qualification
Required
Associate's degree in Nursing (ADN) required
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
RN - Registered Nurse - State Licensure and/or Compact State Licensure Registered Nurse licensed in the State of Maryland Upon Hire required
DL NUMBER - Driver License Valid and in State (DRLIC) Upon Hire required
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)
Preferred
Bachelor's degree in Nursing (BSN) preferred
Experience with data collection and reporting; community outreach experience working in an ambulatory setting preferred
CCM - Certified Case Manager from a nationally recognized certification agency within 1-1/2 Yrs preferred
Company
MedStar Health
MedStar Health is a not-for-profit healthcare organization
10001+ employees
H1B Sponsorship
MedStar Health has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (12)
2024 (13)
2023 (14)
2022 (14)
2021 (12)
2020 (14)
Funding
Current Stage
Late StageTotal Funding
$29MKey Investors
American Medical AssociationAgency for Healthcare Research and QualityA. James and Alice B. Clark Foundation
2023-06-21Grant
2022-09-27Grant· $2M
2020-07-03Grant· $27M
Leadership Team
David Mayer
Executive Director MedStar Institute for Quality and Safety Quality and Safety CEO Patient Safety Mo
Recent News
2025-12-17
Maryland Daily Record
2025-12-05
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