Care Manager

About the Role

The Care Manager will work with primary care practices as a part of the Primary Care Program. The care manager collaborates with the care team within each practice and leverages Aledade’s interdisciplinary care team to provide telephone-based health coaching, quality improvement, and care coordination. The care manager works closely with Medicare patients to support them in becoming active in their health care by better understanding their chronic conditions, helping them access care in the most appropriate setting, and improving quality of care. Care Managers utilize Aledade’s proprietary population health tool, the “Aledade App” to manage high-risk patients, using real-time data to identify and intervene on high utilizers who could benefit from more preventative and active management.

Primary Duties

Longitudinal Care Management (LCM)

Conduct comprehensive assessments covering medical, behavioral, pharmaceutical, and social needs (SDOH) to identify gaps in care and health barriers.

Develop, maintain, and risk-stratify (High, Medium, Low) patient-centered care plans for an active longitudinal caseload equal to at least 5% of MDPCP attribution.

Deliver individualized education and self-management support using Motivational Interviewing (MI) techniques to address ambivalence, increase self-efficacy, and actively engage patients in managing chronic conditions.

Advocate for patients across the care continuum by building effective relationships with caregivers, practice clinicians, and community partners.

Episodic Care Management (ED & TCM)

Execute structured Episodic and Transitional Care Management (TCM) outreach following inpatient discharges and ED encounters within required timeframes.

Complete required post-discharge medication reconciliations and facilitate scheduling of face-to-face follow-up visits.

Provide structured post-discharge follow-up support to reduce unnecessary readmissions and emergency department utilization.

Provider Office & Care Team Collaboration

Partner directly with primary care physicians and practice care teams to identify high-risk patients and co-design appropriate clinical care plans.

Lead and participate in periodic complex care rounds and interdisciplinary case reviews.

Leverage health information exchanges (CRISP ENS alerts) and population health management tools (Aledade App) to monitor high-utilizers and maintain closed-loop documentation within practice EHRs.

Support Staff Oversight & Quality Administration

Provide clinical oversight to non-licensed support staff (e.g., health coaches, patient navigators, community health specialists) and delegate supportive care coordination tasks appropriately.

Support implementation of population health initiatives (e.g., virtual behavioral health, advance care planning, end-of-life care resources).

Monitor, measure, and drive performance across clinical, financial, and functional quality metrics in alignment with Maryland Primary Care Program (MDPCP) standards.

Minimum Qualifications

• Current active licensed Registered Nurse in Maryland
• 3-5 years of direct healthcare experience, preferably in home health, ambulatory care, community public health, case management, or care coordination across multiple settings with multiple providers

Preferred KSA’s

• Proficiency with Health Information Exchanges (HIE), specifically CRISP ENS alerts, and predictive population health management tools
• Certified Case Manager (CCM) credential or specialized training in Chronic Care Management (CCM) — encouraged
• Demonstrated experience utilizing Motivational Interviewing (MI) techniques, with exceptional written and oral communication skills, to drive patient engagement, goal setting, and health behavior change, and to positively influence others with respect and compassion
• Familiarity with the healthcare community being served, or a demonstrated commitment to learn it through on-the-ground networking and community assessment
• Understanding of quality metrics
• Knowledge and experience activating patients and teaching self-management skills
• Experience working with vulnerable populations (geriatrics, minorities, behavioral health), and ability to navigate ambiguity using structured problem-solving techniques

Physical Requirements

Sitting for prolonged periods of time. Extensive use of computers and keyboard. Occasional walking and lifting may be required. Ability to travel up to 20% across the year as needed to assigned primary care practices throughout Maryland and D.C., as well as to regional team retreats (which may occasionally occur outside the immediate area).