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
Work Shift

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

Additional Job Description
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

If 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.

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