RN Coordinator - Advanced Primary Care Management

Job Description SummaryThe 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.EntityMUSC Community Physicians (MCP)Worker TypeEmployeeWorker Sub-Type​RegularCost CenterCC005802 MCP - Population Health Transitional Care Management (TCM)Pay Rate TypeSalaryPay GradeHealth-29Scheduled Weekly Hours40Work ShiftJob DescriptionAdvanced Primary Care Management (APCM)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.Conduct ongoing telephonic and/or virtual outreach to an assigned patient panelDeliver longitudinal, non–face-to-face care management services in alignment with APCM requirementsPerform proactive outreach to engage patients and maintain continuity of careAssess patient status, including changes in condition, symptoms, and care needsDevelop, review, and update individualized care plans and patient-centered goalsSupport medication management, adherence, and reconciliationIdentify 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 careFacilitate communication across interdisciplinary teams, including primary care, specialists, and ancillary servicesProvide patient education on chronic disease management, preventive care, and self-management strategiesParticipate 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 modelsRequired Skills & CompetenciesStrong clinical assessment and critical thinking skillsExcellent communication and patient engagement abilitiesAbility to manage complex patient populations and prioritize care needsKnowledge of chronic disease management, primary care principles, and population healthUnderstanding 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 skillsAbility to work independently and contribute to program developmentAnalytical mindset with ability to identify improvement opportunitiesQualificationsRegistered 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 healthExperience working with high-risk or chronic condition populations strongly preferredPrior experience in program development, quality improvement, or workflow design preferredAdditional Job DescriptionBenefits:Health, dental, vision, and life insuranceEmployer Sponsored Retirement PlanPaid time off and extended sick leavePaid Parental LeaveDisability insurance plan optionsContinuous professional and clinical trainingCompetitive payAnnual Merit IncreaseWellbeing resourcesTuition ReimbursementEmployee perks and discountsEmployee referral programFlexible schedule optionsCertification incentive programIf you like working with energetic enthusiastic individuals, you will enjoy your career with us!The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need. Medical University of South Carolina participates in the federal E-Verify program to confirm the identity and employment authorization of all newly hired employees. For further information about the E-Verify program, please click here: http://www.uscis.gov/e-verify/employees