Location: Baltimore, MD
Cap-Exempt H-1B Position — No lottery required
About this Job: **General Summary of Position** Serves as a member of the interdisciplinary care management team capable of furnishing an array of care coordination services to Medicare FFS beneficiaries attributed to practices that the Care transformation Organization (CTO) supports; Responsible for the care coordination of Medicare FFS beneficiaries attributed to a medical practice(s); Serves as the liaison between the medical practice and the CTO's interdisciplinary care management team. **Primary Duties and 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 episodic care needs and coordination of care for a panel of attributed Medicare beneficiaries following discharge 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); Assists patients with scheduling appointments with providers including annual wellness visits. Review of Discharge instructions and Medication Reconciliation - Attributed beneficiaries receive a follow up interaction from the TOC Care manager coordinator within 2 business 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 i