Registered Nurse Case Manager, Care Delivery

University of Maryland Medical System•Linthicum Heights, MD

About The Position

The RN Care Manager is responsible for applying the nursing process, evidence-based practice, and care management principles to support heart failure patients enrolled in the Heart Failure Bridge Clinic. This role focuses on outreaching to high-risk patients, coordinating care across settings, supporting medication and symptom management, and fostering patient engagement and self-management. The RN Care Manager collaborates closely with physicians, pharmacists, social workers, care coordinators, and administrative staff to ensure seamless transitions of care and to address medical, behavioral, and social needs that influence health outcomes.

Requirements

Licensure as a Registered Nurse in the state of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, is required
3 to 5 years of care coordination experience and/or experience working in an outpatient ambulatory setting
Experience with educating patients and patient goal setting (essential)
Knowledge and experience with managing and overseeing the comprehensive assessment, planning, implementation and overall evaluation of individual patient needs
Proficient analytical, organization, and problem-solving skills to identify opportunities, to implement efficient work processes as it relates to case management
Proficient documentation skills to maintain client records
Ability to work effectively in a stressful work environment and handle confidential issues with integrity and discretion
Critical thinking skills to analyze and solve problems
Strong problem management strategies and issue resolution skills
Excellent interpersonal, verbal, and written communication skills
Strong organization skills, detail oriented, and knowledgeable
Ability to work independently and effectively in a fast pace environment.
Ability to work productively in a stressful environment and effectively handle multiple projects and changing priorities.
Ability to effectively present information and respond to questions from families, members, providers, and clients, as well as the ability to relate effectively to upper management
Ability to work independently, handle multiple assignments, establish priorities, and demonstrate high level time management skills
Understands benefit/payer systems and reimbursement structures for patients.
Strong clinical knowledge of broad range of medical practice settings and healthcare delivery systems
Thorough and solid knowledge of health care and managed care delivery systems. This includes standards of medical practice, insurance benefits structure, and the utilization and case management process.
Knowledge of state and federal laws and resources
Proficiency in Microsoft Office including Outlook, Word, Excel and PowerPoint; knowledge of or the ability to learn care management/EMR software (e.g., Epic) and other software in order to perform job duties

Nice To Haves

BSN preferred
Case Management Certification (preferred)
Experience in a manage care information environment (preferred)
Preferred experience would include knowledge of quality improvement processes (LEAN or PDSA); practice re-design work such as patient centered medical home and Joint Commission and National Committee for Quality Assurance (NCQA) accreditations.

Responsibilities

Apply the nursing process and evidence-based standards to assess patient needs and guide care planning.
Evaluate clinical, psychosocial, and environmental factors impacting heart failure management and recovery.
Identify patients who may benefit from telephonic and virtual outreach and initiate care management interventions.
Participate in remote patient monitoring and support self-management skills.
Analyze utilization patterns including inpatient admissions, ED visits, readmissions, and high-cost utilization.
Develop population-based strategies to improve quality, reduce avoidable utilization, and enhance patient engagement.
Manage active cases based on acuity and intensity, ensuring timely follow-up and escalation when needed.
Track and support transitions of care, ensuring “warm handoffs” between hospitals, emergency departments, clinics, and community settings.
Coordinate follow-up appointments, diagnostic testing, and referrals to pharmacy, behavioral health, and specialty services.
Facilitate communication among all members of the care team to minimize fragmentation and ensure continuity.
Establish collaborative partnerships with patients and caregivers to support self-management, lifestyle changes, and adherence to treatment plans.
Educate patients on heart failure management, medication adherence, symptom monitoring, and available community resources.
Advocate for patients and help them navigate medical, behavioral, and social service systems.
Screen for SDOH barriers and connect patients to community resources addressing transportation, food insecurity, housing, medication access, and more.
Consult with external agencies to coordinate support services.
Document all assessments, interventions, and communications in the EMR and care management platforms.
Participate in chart audits, quality reviews, and program evaluation activities.
Ensure compliance with federal and state regulations, case management standards, and HIPAA requirements.
Report critical incidents and quality-of-care concerns promptly.
Work collaboratively with physicians, pharmacists, social workers, care coordinators, and administrative leaders to design and implement care management protocols.
Provide mentorship and clinical guidance to chronic disease care coordinators and other team members.
Delegate appropriate tasks to support staff while maintaining oversight of patient outcomes.
Participate in special projects and contribute to program development.