Community Registered Nurse-Medicine

Under supervision of the Nurse Manager and/or clinical Nurse Practitioner (NP), 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
• Receives referrals from clinic staff and assists with the identification of high risk/high utilizer patients using available electronic resources and databases (CRISP) and maintains a patient registry.
• Works on or with a multi-disciplinary 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. May require home and/or community visits with patients as well as some office-based work.
• 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.

• 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 preferred

• 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: https://www.umfpi.org/jobs/summary-employee-ben [https://www.umfpi.org/jobs/summary-employee-benefits]