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Care Coordinator RN

2 months ago

Annapolis, Maryland, United States Luminis Health Full time
Job Title: Community Care Manager RN

Join Luminis Health as a Community Care Manager RN and play a vital role in ensuring the highest quality care for our patients. As a member of our team, you will work collaboratively with physicians, staff, and other healthcare professionals to provide care coordination and ensure that safety, best practices, and high-quality standards are maintained across the continuum.

Key Responsibilities:
  • Assist patients through the healthcare continuum as a patient advocate, navigator, and liaison to providers and/or community resources.
  • Participate in team meetings and quality improvement initiatives, and provide feedback to staff to improve the care and referral processes.
  • Facilitate health and disease patient education and support patient self-management of disease and behavior modification interventions.
  • Coordinate continuity of patient care with providers across the healthcare system, including post-hospital or ED discharge.
  • Use high-risk screening criteria to identify and manage high-risk patients, including patients with multiple comorbidities or at risk of readmission.
  • Conduct comprehensive preventive screenings for patients.
  • Facilitate patient medication management.
  • Collaborate with patients, care team, and providers to understand patient short and long-term goals and set patient care plans.
  • Participate on teams for data collection, health outcomes reporting, clinical audits, and programmatic evaluations related to the Maryland Primary Care Program.
  • Evaluate clinical care, resource utilization, and development of new clinical tools, forms, and procedures.
Requirements:
  • RN required, BSN preferred.
  • At least 5 years of experience in healthcare with care management experience.
  • RN license.
  • CPR Certification (obtained within 6 months of start date).
  • Case Management Certification strongly preferred.
Working Conditions:

There is a reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.