Care Manager

The Care Manager at 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). Who We Are: Aledade PBC, a public benefit corporation, exists to empower the most transformational part of our health care landscape - independent primary care. We were founded in 2014, and since then, we've become the largest network of independent primary care in the country - helping practices, health centers and clinics deliver better care to their patients and thrive in value-based care. Additionally, by creating value-based contracts across a wide variety of health plans, we aim to flip the script on the traditional fee-for-service model. Our work strengthens continuity of care, aligns incentives and ensures primary care physicians are paid for what they do best - keeping patients healthy. If you want to help create a health care system that is good for patients, good for practices and good for society - and if you're eager to join a collaborative, inclusive and remote-first culture - you've come to the right place. What Does This Mean for You? At Aledade PBC, you will be part of a creative culture that is driven by a passion for tackling complex issues with respect, open-mindedness and a desire to learn. You will collaborate with team members who bring a wide range of experiences, interests, backgrounds, beliefs and achievements to their work - and who are all united by a shared passion for public health and a commitment to the Aledade mission. In addition to time off to support work-life balance and enjoyment, we offer the following comprehensive benefits package designed for the overall well-being of our team members: Flexible work schedules and the ability to work remotely are available for many roles Health, dental and vision insurance paid up to 80% for employees, dependents and domestic partners Robust time-off plan (21 days of PTO in your first year) Two paid volunteer days and 11 paid holidays 12 weeks paid parental leave for all new parents Six weeks paid sabbatical after six years of service Educational Assistant Program and Clinical Employee Reimbursement Program 401(k) with up to 4% match Stock options And much more! At Aledade PBC, we don’t just accept differences, we celebrate them! We strive to attract, develop and retain highly qualified individuals representing the diverse communities where we live and work. Aledade is committed to creating a diverse environment and is proud to be an equal opportunity employer. Employment policies and decisions at Aledade are based on merit, qualifications, performance and business needs. All qualified candidates will receive consideration for employment without regard to age, race, color, national origin, gender (including pregnancy, childbirth or medical conditions related to pregnancy or childbirth), gender identity or expression, religion, physical or mental disability, medical condition, legally protected genetic information, marital status, veteran status, or sexual orientation.