RN Care Coordination Lead for Medicare

MedStar Health; Cherry Valley (MD); On-site; USD 89,000 - 163,000; Full time

Job summary

MedStar Health in Maryland seeks an RN CTO Lead Care Manager to coordinate care for Medicare FFS beneficiaries attributed to CTO across practices. This role requires travel to the Silver Spring office and occasional coverage at Chevy Chase.

The RN will liaison between the practice and CTO teams, manage a caseload, and lead care planning with a focus on timely access, follow-up after hospital/ED events, and coordination with specialists.

Qualifications

• 3–4 years work experience including 1+ year of proven case management.
• Familiarity with the local area and population health workforce integration.
• Experience with data collection and reporting; ambulatory setting experience preferred.

Responsibilities

• Coordinate care for a panel of attributed Medicare beneficiaries and act as liaison between practice and CTO care team.
• Ensure timely access to care and facilitate alternatives to traditional office visits.
• Facilitate referrals to high-volume/high-cost specialists and EDs; support PFAC engagement and advance care planning.
• Under physician direction, perform direct patient care including wellness visits and screenings as needed.
• Monitor and adjust care plans; ensure EMR documentation and data exchange across teams.

Skills

Verbal communication

Written communication

Interpersonal skills

Analytical thinking

Project management

Cultural competency

EMR data entry

Education

Associate's degree in Nursing (ADN)

Bachelor's degree in Nursing (BSN)

RN - State Licensure

CCM - Certification

Driver License

Job description

MedStar Health in Maryland seeks an RN CTO Lead Care Manager to coordinate care for Medicare FFS beneficiaries attributed to CTO across practices. This role requires travel to the Silver Spring office and occasional coverage at Chevy Chase.

The RN will liaison between the practice and CTO teams, manage a caseload, and lead care planning with a focus on timely access, follow-up after hospital/ED events, and coordination with specialists.