Community Registered Nurse-Medicine

University of Maryland Faculty Physicians•Baltimore, MD

19h•Hybrid

About The Position

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.

Requirements

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

Nice To Haves

Two to three years clinical experience preferred

Responsibilities

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.