RN Coordinator - Advanced Primary Care Management

Medical University of South Carolina•Remote- South Carolina, SC

3d•Remote

About The Position

The Advanced Primary Care Management (APCM) Registered Nurse (RN) Coordinator is responsible for delivering comprehensive, continuous care management services to patients, with a focus on longitudinal primary care support, chronic disease management, and population health improvement. This role combines direct patient care and engagement with programmatic development, implementation, and optimization responsibilities to support the growth and sustainability of APCM services. The APCM RN plays a key role in improving patient outcomes, enhancing care coordination, reducing avoidable utilization, and advancing value-based care initiatives. This position reports to the Manager, Chronic Care Management.

Requirements

Registered Nurse (RN) with active, unrestricted licensure (South Carolina preferred)
BLS (Basic Life Support) certification (if required by role)
Minimum of 2 years of experience in care coordination, case/care management, ambulatory care, or population health
Strong clinical assessment and critical thinking skills
Excellent communication and patient engagement abilities
Ability to manage complex patient populations and prioritize care needs
Knowledge of chronic disease management, primary care principles, and population health
Understanding of value-based care models and care management reimbursement structures (including APCM)
Proficiency in EHR documentation and care coordination workflows (Epic preferred)
Strong organizational, time management, and multitasking skills
Ability to work independently and contribute to program development
Analytical mindset with ability to identify improvement opportunities

Nice To Haves

Experience working with high-risk or chronic condition populations strongly preferred
Prior experience in program development, quality improvement, or workflow design preferred

Responsibilities

Conduct ongoing telephonic and/or virtual outreach to an assigned patient panel
Deliver longitudinal, non–face-to-face care management services in alignment with APCM requirements
Perform proactive outreach to engage patients and maintain continuity of care
Assess patient status, including changes in condition, symptoms, and care needs
Develop, review, and update individualized care plans and patient-centered goals
Support medication management, adherence, and reconciliation
Identify and address barriers to care (e.g., social determinants of health, access issues)
Collaborate with providers, care teams, and community resources to ensure continuity and quality of care
Facilitate communication across interdisciplinary teams, including primary care, specialists, and ancillary services
Provide patient education on chronic disease management, preventive care, and self-management strategies
Participate in the design, development, and implementation of APCM program workflows, protocols, and standard operating procedures (SOPs)
Contribute to optimization of care management processes, including outreach strategies, documentation standards, and patient engagement models