Job Description

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.

• Develops, implements and evaluates population health strategies to reduce PAU in close collaboration with internal and external partners.
  • Responsible for the implementation, management and evaluation of processes that focus on the safe return of the patient to the community and fosters collaboration between primary and specialty care medical practices.
  • Develops annual implementation plans and reports.
  • Effectively manages the department budget.
  • Supervises teams that support PAU reduction initiatives. Develops care plan for complex patients, and participate in other PAU reduction initiatives.
  • Supervises ambulatory care Nurse Care Coordinators, Social Workers, and Community Health Workers. Develops resources that meet patient deficits in the Social Determinants of Health.
  • Collaborates with the interdisciplinary team, patients and/or caregivers to determine interventions to be addressed during and post hospitalization for patients identified as high risk for readmission. Collaborates with the interdisciplinary team, patients and/or caregivers to determine interventions to be addressed to reduce ED utilization.
  • Seeks cutting edge interventions, methodologies, and best practices for ED and readmission reduction via research, webinars, in-services, networking, etc. and effectively communicate action plans with leadership for review
  • Ensures ED visit and readmission causes and solutions are tracked and trended for outcome analysis.
• Serves as a resource for nursing, physicians, and care management staff. Develops educational tools for teaching and training the interdisciplinary team, patients, and caregivers.
  • Develops, maintains, and extends knowledge and expertise in population health, discharge coordination and care transitions, chronic disease management processes, patient education, and community resources.
  • Serves as a resource for population health improvement initiatives within UMMC, UMMS and the community.
• Effectively develops processes, protocols and/or other tools to communicate high risk findings and interventions with appropriate members of the interdisciplinary team.
  • Provides strategic solutions and oversight of the discharge planning and care transitions process for patients at high risk for ED utilization and/or readmission.
  • Collaboratively develops and coordinates protocols for follow-up appointments, post discharge lab/tests, transportation, alternative ways of getting medications (if applicable), and other services as needed.
  • In collaboration with appropriate departments, provides strategic solutions to expedite transmission of discharge instructions and discharge summaries to clinicians following the patient’s discharge.
  • Works with CRISP to facilitate the sharing of Health Information Exchange (HIE).
• Collaborates in the development of short and long-term goals for reducing PAU, especially readmissions. ****
  • Demonstrates a commitment to goals and promotes teamwork with other associates within and outside of the Population Health department.
  • Participates in hospital wide and external committees, work groups, teams, etc. as appropriate to advance the goals of the organization to reduce PAU and facilitate the patients safer return to the community.
• Performs all other duties as assigned.

Qualifications

Bachelor’s degree in nursing, public health, or related field.

• Active licensure as a Registered Nurse in the state of Maryland required.

• Three (3) to Five (5) years of experience in case management, care transitions, case management, disease management, or population health is required.

Additional Information

All your information will be kept confidential according to EEO guidelines.

Compensation:
Pay Range: $44.76-$67.19
Other Compensation (if applicable):
Review the 2025-2026 UMMS Benefits Guide

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