Job Description

Under supervision of the Nurse Manager, the Nurse Care Coordinator will work in collaboration and continuous partnership with the high risk and/or high utilizer patients and their family/caregiver(s), clinic/hospital/specialty providers and staff, as well as 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 general and specialty professional standards, and functions within the multidisciplinary practice model.

ESSENTIAL FUNCTIONS

• Assists with the identification of high risk/high utilizer patients using available electronic resources and databases and maintains a patient registry.
• Works a multidisciplinary team including social work, pharmacy, diabetes educator, nurses and in collaboration with the patient, primary care provider and family/caregivers to create care plans for patients including high-risk, high utilizer patients, patients with multiple co-morbidities and/or at high risk for readmission to a hospital setting.
• Works with patients both in person and on the phone to monitor adherence to care plans, evaluate effectiveness, monitor patient progress, and facilitate change as needed.
• Assists patients through the healthcare system by acting as a patient advocate and navigator and promoting timely access to appropriate care.
• Promotes clear communication between care teams and treating clinicians by ensuring awareness regarding patient care plans and being mindful of cultural and language preferences of patients.
• Provides outreach and transitional care management to patients discharged from the hospital, emergency room or rehab facility.

EDUCATION and/or EXPERIENCE

• Bachelor's Degree, or diploma in Nursing from an Accredited institution
• Current Maryland licensure or eligibility to obtain Maryland licensure
• Excellent customer service and communication skills
• Two to three years clinical experience.

Total Rewards

The referenced base salary range represents the low and high end of University of Maryland’s Faculty Physician’s Inc. salary range for this position. Some candidates will not be eligible for the upper end of the salary range. Exact salary will ultimately depend on multiple factors, which may include the successful candidate's geographic location, skills, work experience, market conditions, internal equity, responsibility factor and span of control, education/training and other qualifications. University of Maryland Faculty Physician’s Inc. offers a total rewards package that supports our employees' health, life, career and retirement. More information can be found here:

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Job Tags

Work experience placement,

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