RN Clinical Care Coordinator

Baltimore Area, Prince George's County, Montgomery County
To be discussed
Nov 05, 2020
Dec 04, 2020
Contract Type
Full Time

The Clinical Care Coordinator is a licensed registered nurse (RN) who, as part of the multidisciplinary team, provides day-to-day care management and coordination services, as determined by individualized plans of care, for Medicaid MCO members with complex and chronic health care needs. Clinical Care Coordinators at The Coordinating Center subscribe to the definition of case management and ethical statements guiding case management practice as determined by The Case Management Society of America, and adhere to The Coordinating Center’s mission, vision and values, helping clients and families “achieve their aspirations for independence, health and meaningful community life.” Clinical Care Coordinators rely on support from other members of the multidisciplinary team and are required to travel throughout the state of Maryland to visit clients in their homes, hospitals, physician offices, nursing facilities, schools, and other residential facilities on a monthly basis. Senior Clinical Care Coordinators and Program Directors provide consultation, health and community care expertise, policy liaison and direction, as well as face to face support and mentoring. Clinical Care Associates perform a variety of administrative functions, which support Clinical Care Coordinators.

This is a teleworking position. While most of the Coordinator’s day will be spent in the field with clients, hot spots and conference spaces can be accessed for individual coworkers and group meetings and trainings at The Coordinating Center in Millersville. (During the COVID-19 pandemic, you will not be required to visit the office or clients in the community)

Essential Responsibilities

  • Completion of a thorough assessment on all new referrals to The Coordinating Center and reassessments as required.
  • Work closely with the client/caregiver and Community Health Worker to develop an individualized, collaborative plan of care to address barriers to care, gaps in care and social determinants of health.
  • Utilization of evidenced based interventions to promote health, wellness and self-management skills to meet the client’s health and safety needs.
  • Utilization of the case management process to guide service delivery.
  • Provision of education on disease management, early interventions to reduce hospital utilization, current benefits through insurer and improved self-management skills
  • Identification of community resources and services to meet health and safety needs Monitoring of plan of care and updating plan of care to document progress towards meeting goals ; including the development of new goals identified during client contacts
  • Documentation of all activities in appropriate system on timely basis and maintenance of care management records.
  • Provision of assistance to physicians and other providers in navigating systems to access all appropriate Medicaid and insurance funded services.
  • Maintain ongoing communication with other members of the health care team and partners.
  • Actively participate in all administrative and clinical rounds as needed to meet client goals and contractor requirements.
  • Maintain regular communication with the Community Health Worker regarding all client’s current plan of care, need for reassessment and clinical support.
  • Provide support and guidance to the Community Health Worker as indicated.
  • The Clinical Care Coordinator will maintain regular contact with all clients, their natural supports and clinical team through community visits and telephone contact as required by levels of care.
  • The Clinical Care Coordinator will display an understanding of the requirements of both URAC and NCQA certifications.


  • RN with active Maryland License
  • Associate degree or Bachelors of Science degree in nursing (preferred)
  • CCM certification is preferred and is required within two years of the date of employment at The Center
  • Minimum three years’ experience with adult and pediatric clients in one or more of the following areas:
    • insurance care management
    • community health
    • rehabilitation nursing
    • hospital setting
  • Additionally, Clinical Care Coordinators will demonstrate high clinical competence, an ability to work in a team situation with other professionals and have the ability to carry out responsibilities with minimal supervision
  • Proof of current state licensure and current malpractice insurance coverage is required
  • Maintenance of certifications as they apply to care coordination e.g. CCM, RNC, et cetera
  • Ability to travel throughout the state of Maryland estimated to average about 50% of work schedule

In addition to the above qualifications the successful incumbent is expected to consistently demonstrate:

  • Positive working attitude that supports the needs of the care management team
  • Support of the mission and values of The Coordinating Center with a commitment to a person-centered, family-centered, culturally competent philosophical base.
  • Commitment to continuous quality improvement working with co-workers in a team oriented collaborative governance model.
  • Flexibility and the ability to adapt to the changing healthcare environment and legislation.

For more information about this job and our organization, please visit our website at www.coordinatingcenter.org