Population Health RN Care Coordinator

Chase Brexton Health Care

Baltimore (MD)

Hybrid

USD 70,000 - 85,000

Full time

14 days+

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Job summary

Chase Brexton Health Care seeks a Population Health RN Care Coordinator committed to enhancing patient outcomes. This hybrid role involves case management and collaboration to ensure complex patients receive comprehensive, culturally sensitive care. Ideal candidates will have significant nursing experience, particularly with vulnerable populations, and possess strong communication and analytical skills.

Qualifications

At least five years of related nursing experience serving vulnerable clients.
Experience in chronic disease management.
Preferred: Case Management Certification.

Responsibilities

Deliver and oversee care management services for complex patients.
Develop and implement patient-centered care strategies.
Collaborate with multidisciplinary teams to achieve health goals.

Skills

Motivational interviewing

Complex case management

Patient advocacy

Education

Graduate from an Accredited School of Nursing

Current Maryland Nursing License

Tools

Electronic Medical Record

Job description

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Join to apply for the Population Health RN Care Coordinator role at Chase Brexton Health Care

Chase Brexton Health Care provided pay range

This range is provided by Chase Brexton Health Care. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

Base pay range

$70,000.00/yr - $85,000.00/yr

JOB SUMMARY: The Nurse Care Coordinator delivers and oversees care management services for medically and/or socioeconomically complex patients in accordance with patient-defined goals, multi-disciplinary plan of care, and established policies and procedures. Drawing on best practices in motivational interviewing and care management, the Nurse Care Coordinator collaborates with clients and multi-disciplinary teams to develop and implement flexible, patient-centered, and cost-effective strategies that support clients to achieve health-related goals. The Nurse Care Coordinator will collect and analyze patient-level data, assist with development and maintenance of care plans, and evaluate outcomes of interventions. The Nurse Care Coordinator also serves as a role model and mentor to CBHC staff on best practices in care coordination, motivational interviewing and addressing social determinants of health. Assures compliance with regulatory body standards (including Joint Commission, HRSA, PCMH, and grant funding sources). This is a hybrid position, and the staff member is expected to be licensed and based in Maryland.

Major Duties And Responsibilities

Analytical and Critical Thinking

Work to develop systems and processes to engage patients in self-management and care navigation.

Ensure that appropriate community resources, home care and ancillary services are in place and being delivered.
Identify high and rising-risk, high-need, and potentially high-cost patients within the assigned panel of Chase Brexton Health Care patients
Identify patients at risk for poor outcomes and those who may require more intensive services; provide additional outreach and frequent follow up (by phone and in-person) to this population.
Provide complex case management, including chronic disease case management, care coordination, transition care management, high risk clinical tracking, and complex medication management to appropriate patients.
Access appropriate resources inside and outside the organization to meet the needs of the patient.
Provide referrals to appropriate community resources; facilitate access and communication when multiple services are involved; monitor activities to ensure that services are actually being delivered and meet the needs of the patient, coordinate services to avoid duplication. Teamwork
Role model and mentor others, including RN Care Managers, to assess and address the physical, functional, social, psychological, environmental, learning and financial needs of patients.

Communication

Deliver, and assist others to also provide, appropriate interventions which demonstrate knowledge of, and sensitivity toward, cultural diversity and religious, developmental, health literacy, and educational backgrounds of the population served. Utilize interpreter services per policy.
Facilitate disease prevention and health promotion with nursing staff, patients and families. Patient Focus
Provide education, information, and support related to care goals of patients.
Act as a patient advocate and assist with problem solving and addressing any barriers to care or compliance with care plan. Checking, Examining, and Recording
Maintain accurate patient records and patient confidentiality. Willingness to Learn
Engage in professional development activities to keep abreast of care management practices and patient engagement strategies.
Attend training sessions and staff meetings as assigned.

SKILLS AND ABILITIES:

Able to prioritize competing responsibilities and manage complex caseloads.

Motivational interviewing skills.
Supportive coaching and mentorship to colleagues at clinic sites, including RN Care Managers, around care coordination and addressing social determinants of health.
Experience with documentation in an Electronic Medical Record
Ability to work with computers in word processing, and database applications preferred.
CPR certified by scheduled start date.
Must be flexible and adapt to a changing environment.

EDUCATION AND/OR EXPERIENCE:

Graduate from an Accredited School of Nursing; Current Maryland Nursing License

At least five years of related nursing experience serving vulnerable clients in a community-based, home-based, or ambulatory care setting.
Chronic disease management experience
Encouraged to maintain membership in professional organizations such as the AAACN, ANAC, etc.

Preferred: Case Management Certification

WORKING CONDITIONS/PHYSICAL DEMANDS:

Work is typically performed in an office environment. Depending on client/population needs, may also include clinical and community and/or home-based activities, as appropriate to program. The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

My signature below indicates that I have reviewed this job description. I understand the specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

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Employee Signature

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