Nurse Care Coordinator - Chase Brexton Healthcare

This is a hybrid position, and the staff member is expected to be licensed and based in Maryland.

MAJOR DUTIES AND RESPONSIBILITIES:

Analytical and Critical Thinking

Work to develop systems and processes to engage patients in self-management and care navigation.

· Ensure that appropriate community resources, home care and ancillary services are in place and being delivered.

· Identify high and rising-risk, high-need, and potentially high-cost patients within the assigned panel of Chase Brexton Health Care patients

· Identify patients at risk for poor outcomes and those who may require more intensive services; provide additional outreach and frequent follow up (by phone and in-person) to this population.

· Provide complex case management, including chronic disease case management, care coordination, transition care management, high risk clinical tracking, and complex medication management to appropriate patients.

· Access appropriate resources inside and outside the organization to meet the needs of the patient.

· Provide referrals to appropriate community resources; facilitate access and communication when multiple services are involved; monitor activities to ensure that services are actually being delivered and meet the needs of the patient, coordinate services to avoid duplication.