Health Home Nurse (Baltimore)


General Summary

Under general supervision the Nurse Care Manager oversees the implementation of the CCG Health Home. This position is accountable for designing and maintaining systems to ensure the continuity of care between the OTP program and somatic and behavioral healthcare providers both within CCG and in the community, as well as developing processes to assist consumers in the development and maintenance of healthy lifestyles and illness management skills. 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 duties performed.

Principal Responsibilities and Tasks

A. Provides implementation and coordination of Health Home activities

  • Leads practice transformation based on Health Home principles and state/accrediting body requirements.
  • With agency leadership, acts as a “champion” for the Health Home philosophy and provides education to staff.
  • Develops and maintains working relationships with primary and specialty care providers including inpatient facilities and emergency departments.
  • Monitors Health Home performance at the population and participant level, and implements improvement efforts.
  • Designs and develops prevention and wellness initiatives.
  • Establishes the effective use of patient registries (CRISP and eMedicaid) as applicable to manage specific patient populations and to improve disease and population health outcome measures.
  • Collaborates/consults with specialty practices to identify data needs related to care coordination.
  • Provides input for the preparation of the annual Health Home operating budget.
  • Monitors participants’ monthly visits to assure the appropriate health home services are delivered.
  • Oversees the entering of all required data into eMedicaid
  • Manages the 24 hour telephone for emergency clinical needs during hours the center is closed

B. Provides health home service planning needs of assigned persons

  • Evaluates/assists in evaluation of appropriateness of plan of care and revises on an ongoing basis with communication to all other disciplines
  • Reviews results of laboratory tests and other diagnostic procedures and reports to the nurse practitioner or psychiatrist.
  • Identifies significant clinical findings, makes conclusions and intervenes appropriately under the direction of the nurse practitioner consultant.
  • Compares ongoing outcome data to baseline data to monitor clients.
  • Initiates client education based on identified learning needs of the client and/or those providing care and documents appropriately
  • Supports and monitors compliance of the individual including checking of prescription labels and storage.
  • Consults with behavioral health staff about participants’ identified health conditions
  • Attends treatment team meetings with behavioral health staff to plan and coordinate care
  • Assists in contacting medical providers & hospitals for coordination of care efforts
  • Provides training on medical diseases, treatments, & medications to health home participants.

C. Assists in the training and education of OTP staff regarding health home services.

  • Provides training on medical diseases, treatments, & medications to behavioral health staff, as indicated.

D. Other duties as assigned.

 Qualifications and Requirements

  • Licensure as a Registered Nurse in the state of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, is required.
  • Demonstrated success in exhibiting teaching, coaching, and development skills.
  • Demonstrated effectiveness in a consultative role, and experience leading complex change.
  • Ability to create a motivating environment for clinical and professional personnel.
  • Highly effective interpersonal, verbal, and written communication and presentation skills. The successful
  • Demonstrate effectiveness as a group leader and participant. Demonstrate ability to collaborate with Ability to plan, organize and follow
  • Knowledge of the Maryland healthcare industry and policy, preferred.
  • Ability to analyze and conceptualize data to ensure achievement of desired outcomes.
  • Technically proficient in Microsoft Office programs and database use. Ability to learn and use an electronic medical record and health information exchange to enter clinical information and run reports.

Lines of Reporting and Communication

This position reports to the Health Home Nurse Care Manager Director

 Patient Safety

Ensures patient safety in the performance of job functions and through participation in CCG patient safety initiatives.

  •  Takes action to correct observed risks to patient safety.
  • Reports adverse events and near misses to supervisor.
  • Implements policies, procedure, and standards consistently in the performance of assigned duties.
  • Develops effective working relationships and maintains good communication with other team members.

Identifies possible risks in processes, procedures, devices and communicates the same to those in charge.


We will review your resume and respond to you within the next few business days. Thank you for your interest in joining the Concerted Care Group!

Concerted Care Group Baltimore, LLC is committed to Equal Employment Opportunity (EEO) and is committed to compliance with all Federal, State and local laws that prohibit employment discrimination on the basis of race, color, age, natural origin, ethnicity, religion, gender, pregnancy, marital status, sexual orientation, citizenship, genetic disposition, disability or veteran’s status or any other classification protected by State/Federal laws. Concerted Care Group, LLC offers competitive salaries and professional, rewarding work environment.