Schedule: Weekend/Weekday EVERY Saturday and Sunday plus 2 weekdays (four 10 hour shifts)

Job Summary

Delivers patient-centered care management through comprehensive assessment, individualized care planning, care coordination, and ongoing monitoring of patient needs. Facilitates communication among patients, caregivers, healthcare providers, and community resources to support safe and effective transitions across the continuum of care. Assists patients in navigating healthcare services, available resources, and financial considerations while identifying and addressing barriers to care and promoting self-management. Maintains accurate documentation, ensures compliance with regulatory and organizational requirements, and collaborates with interdisciplinary teams to support quality care and positive health outcomes.

Primary Responsibilities

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job responsibilities performed.

Conduct comprehensive assessments of patients' clinical, psychosocial, functional, financial, and support needs to identify risks, barriers, and opportunities for intervention.

Develop, implement, and monitor individualized care plans that align with patient goals, clinical needs, and evidence-based practices.

Coordinate services and resources across the continuum of care to ensure timely access to appropriate treatments and support services.

Facilitate safe and effective transitions between care settings ensuring coordination of a safe discharge plan and follow up care.

Educate and engage patients and caregivers to support informed decision-making, self-management, and achievement of health goals.

Assist patients in navigating healthcare benefits, community resources, financial assistance programs, and other available services.

Maintain accurate, timely, and compliant documentation in accordance with regulatory, accreditation, and organizational requirements.

Collaborate with interdisciplinary teams to improve care coordination, patient outcomes, and operational effectiveness.

Participate in quality improvement initiatives and professional development activities to maintain current knowledge and skills.

Perform all other duties as assigned.

Education & Experience - Required

Associate degree in Nursing or Bachelor' degree in Physical Therapy.

Current Maryland unrestricted licensure as a Registered Nurse (RN) or Physical Therapist (PT).

One (1) year of healthcare, care coordination, case management, utilization management, or related experience.

Education & Experience Preferred

Bachelor of Science in Nursing (BSN) or other related healthcare field.

Three (3) years of relevant healthcare or case management experience.

Active membership in a relevant professional organization (e.g., ACMA, CMSA, CCMC, ANA, NASW).

Experience in an acute care, managed care, ambulatory, or population health environment.

Specialty certification in case management, utilization management, discharge planning, or a related specialty.

Knowledge, Skills, & Abilities

Care management principles, discharge planning, and transitions of care.

Community resources, healthcare benefits, and patient support programs.

Applicable regulatory and documentation requirements.

Comprehensive patient assessment.

Care plan development and implementation.

Patient and caregiver education.

Documentation and care coordination.

Interdisciplinary communication and collaboration.

Identify patient risks, barriers, and resource needs.

Coordinate services across multiple care settings.

Prioritize competing patient needs and workload demands.

Build effective relationships with patients, families, and healthcare teams.

Contact Name:
Company Name: University of Maryland Medical System
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Website: https://careers.umms.org/us/en/job/...
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