Under supervision of the Nurse Manager, the Nurse Care Coordinator will work in collaboration and continuous partnership with high risk and/or high utilizer patients and their family/caregivers, clinic/hospital/specialty providers, and staff, as well as the full care coordination team to:
Promote timely access to appropriate care, reduce emergency room utilization and hospital readmissions, improve quality metrics, create and promote adherence to care plans, and increase patients’ ability for self-management and shared decision-making.
This role is patient-focused, outcome-oriented, and based on professional standards, functioning within a multidisciplinary practice model.
ESSENTIAL FUNCTIONS
Assist with the identification of high risk/high utilizer patients using electronic resources and maintain a patient registry.
Collaborate with a multidisciplinary team including social work, pharmacy, diabetes educators, nurses, patients, primary care providers, and families to create care plans for high-risk, high-utilizer patients, or those with multiple co-morbidities or at high risk for readmission.
Work with patients both in person and by phone to monitor adherence to care plans, evaluate effectiveness, monitor progress, and facilitate changes as needed.
Assist patients through the healthcare system by acting as an advocate and navigator, promoting timely access to care.
Ensure clear communication between care teams and clinicians, considering patients’ cultural and language preferences.
Provide outreach and transitional care management to patients discharged from hospitals, emergency rooms, or rehab facilities.
EDUCATION and/or EXPERIENCE
Bachelor's Degree or Nursing diploma from an accredited institution.
Current Maryland licensure or eligibility to obtain it.
Excellent customer service and communication skills.
Two to three years of clinical experience.
Total Rewards
The salary range reflects the low and high ends of the University of Maryland’s Faculty Physician’s Inc. salary scale for this position. Salary may vary based on location, skills, experience, and other factors. The university offers a comprehensive benefits package. More information can be found here .
#ZR
Equal Opportunity Employer
This employer is committed to notifying all applicants of their rights under federal employment laws. For more information, review the Know Your Rights notice from the Department of Labor.