Details
Posted: 18-Jun-25
Location: Linthicum Heights, Maryland
Categories:
Allied Health
Internal Number: REF41528I
Job Description
Provides patient-centered, supportive services within a primary care population health model to enhance coordinated, integrated care across the continuum. Functions as part of an interdisciplinary care team, addressing psychosocial and behavioral health needs to promote patient engagement, autonomy, and improved health outcomes. Facilitates connections to appropriate behavioral health and community-based services through advocacy, education, and brief interventions. Supports chronic disease self-management and care plan adherence by identifying social drivers of health and barriers to care, while promoting wellness through proactive outreach and collaboration.
Primary Responsibilities
The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job responsibilities performed.
* Conducts chart reviews to assess for readmission risks within 2 business days of discharge. Identifies care gaps related to targeted chronic conditions and notifies teams of unaddressed clinical concerns.
* Facilitates development and implementation of care plans for medically and socially complex patients in the primary care setting.
* Conducts psychosocial screenings and brief behavioral health interventions to support patients with depression, anxiety, and/or substance use disorders. May require travel to meet with patients face to face.
* Assists patients in setting care goals and developing action plans to address barriers to care and improve self-management of chronic conditions.
* Engages patients with unmet behavioral health needs, coordinating timely referrals and follow-up with mental health specialists as appropriate.
* Interviews patients and caregivers to assess social needs, including housing, food insecurity, transportation, safety, and financial stressors.
* Delegates appropriate tasks to Community Health Workers or other non-licensed care team members and provides oversight to ensure screenings and follow-up activities are completed accurately and in a timely manner.
* Collaborates with the interdisciplinary care team during care rounds to ensure alignment of behavioral health and social care needs with medical plans.
* Connects patients to appropriate community-based resources and support services; monitors referral follow-through and impact on care outcomes.
* Documents assessments, goals, interventions, and outcomes in the electronic health record (EHR) in accordance with departmental and regulatory standards.
* Maintains knowledge of social service systems, entitlement programs, and behavioral health referral processes to support timely resource access.
* Leads or participates in family or care team meetings to ensure care alignment and patient-centered decision-making.
* Delegates appropriate tasks to unlicensed personnel and provides oversight to ensure timely, high-quality support service delivery.
* Builds and maintains a referral network of community agencies and partners to assist patients in navigating health-related social needs.
* Provides education and training to staff on behavioral health integration, care coordination practices, and social determinants of health. May require travel to provider offices or other locations to provide training to UMMS affiliated staff.
* Participates in quality improvement initiatives to enhance care coordination outcomes, patient satisfaction, and system efficiency.
* Demonstrates commitment to professional development through supervision, continuing education, and contribution to care team learning.
* Perform all other duties as assigned.
Company Description
The University of Maryland Medical System (UMMS) is an academic private health system, focused on delivering compassionate, high quality care and putting discovery and innovation into practice at the bedside. Partnering with the University of Maryland School of Medicine, University of Maryland School of Nursing and University of Maryland, Baltimore who educate the state's future health care professionals, UMMS is an integrated network of care, delivering 25 percent of all hospital care in urban, suburban and rural communities across the state of Maryland. UMMS puts academic medicine within reach through primary and specialty care delivered at 11 hospitals, including the flagship University of Maryland Medical Center, the System's anchor institution in downtown Baltimore, as well as through a network of University of Maryland Urgent Care centers and more than 150 other locations in 13 counties. For more information, visit www.umms.org.
Qualifications
Education & Experience - Required
* Bachelor's degree in nursing or Master's Degree in Social Work.
* Current Maryland State or Compact State Licensure as a Registered Nurse or Current Maryland Licensure as a Licensed Clinical Social Worker.
* Minimum 3 years of previous experience in case management, population health, or behavioral health care management.
Education & Experience - Preferred
* Previous experience in transitional care, readmission reduction strategies, community health, or ambulatory behavioral health setting, preferably in primary care, case management or population health.
Knowledge, Skills, & Abilities
* Strong analytical skills to review clinical data and identify care gaps.
* Ability to work independently in a hybrid work setting, while maintaining strong collaboration with multiple stakeholders.
* Knowledge of integrated care models, behavioral health screening tools (e.g., PHQ-9, GAD-7), and brief intervention techniques (e.g., SBIRT, motivational interviewing).
* Familiarity with value-based care principles and population health strategies targeting chronic disease, health equity, and care transitions.
* Experience working with diverse and underserved populations; bilingual preferred.
* Strong interpersonal, organizational, and communication skills, with ability to work independently and as part of a collaborative care team.
* Proficient in use of electronic health records (EHRs), care management platforms, and Microsoft Office applications.
* Requires flexibility to adapt to evolving healthcare data, reporting tools, and case management strategies.
