RN Coordinator - Advanced Primary Care Management

Job Description Summary 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. Entity MUSC Community Physicians (MCP) Worker Type Employee Worker Sub-Type Regular Cost Center CC005802 MCP - Population Health Transitional Care Management (TCM) Pay Rate Type Salary Pay Grade Health-29 Scheduled Weekly Hours 40 Job Description Advanced 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 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 Required Skills & Competencies 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 Qualifications 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 Experience working with high-risk or chronic condition populations strongly preferred Prior experience in program development, quality improvement, or workflow design preferred Benefits Health, dental, vision, and life insurance Employer Sponsored Retirement Plan Paid time off and extended sick leave Paid Parental Leave Disability insurance plan options Continuous professional and clinical training Competitive pay Annual Merit Increase Wellbeing resources Tuition Reimbursement Employee perks and discounts Employee referral program Flexible schedule options Certification incentive program 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: #J-18808-Ljbffr Medical University of South Carolina