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Job Details

High Risk Patient Coordinator (RN)

Requisition #: 184990
Location: Johns Hopkins Hospital/Johns Hopkins Health System, Baltimore, MD 21201
Category: Leadership
Work Shift: Day Shift
Work Week: Full Time (40 hours)
Weekend Work Required: No
Date Posted: July 25, 2019

Johns Hopkins Health System employs more than 20,000 people annually. Upon joining Johns Hopkins Health System, you become part of a diverse organization dedicated to its patients, their families, and the community we serve, as well as to our employees. Career opportunities are available in academic and community hospital settings, home care services, physician practices, international affiliate locations and in the health insurance industry. If you share in our vision, mission and values and also have exceptional customer service and technical skills, we invite you to join those who are leaders and innovators in the healthcare field.

General Purpose: The Population Health Management (PHM) High Risk Patient Coordinator RN is a member of team of care team professionals that support improved care pathway facilitation for appropriate high-risk patients to appropriate clinical and other resources and interventions. This role supports the JHM primary care and other care team members with coordination of care management, appropriate connection to various models and community services for high-risk members in the Outpatient setting. This role supports improving the care delivery to JHM patients enhancing the overall organizational performance.


  1. Assists in developing process and procedures that ensures thorough review of multiple patient level actionable reports; to include but not limited to Gaps in Care, Pre-Vise, in order to identify at risk patients. Coordinates with practices to ensure at risk patients are seen and any gaps in care are closed
  2. Conducts needs assessment to plan projects, coordinates and monitors support services/staff, develops timelines, education needs of physicians and staff
  3. Identifies and refers appropriate patients to eligible programs within JHM such as; Diabetes/Nutrition services, Personal Health Team, Health Advisors, Complex Case Management, etc.
  4. Coordinates the care of the high-risk targeted population in an appropriate, efficient and cost-effective manner.
  5. Evaluates the effectiveness, necessity, and efficiency of the treatment plan and communicates with the PCP and health care delivery team to recommend changes.
  6. Educates self on the critical elements associated with the target population such as disease states, diagnoses (ICD9) codes, utilization patterns, clinical treatment guidelines, financial processes, regulations, data resource quality and availability.
  7. Act as the community resource expert for the primary care practices for our high risk members, including transition of life/hospice resources, direct acute admits and home health/infusion needs.
  8. Identifies cases appropriate for long-term case management and follows process for referral.
  9. Acts as the XYZ expert for the Healthcare centers regarding all of the JHM programs available to this membership.
  10. Works effectively with Complex Case Manager to coordinate case transition when needed
  11. Establish and maintain a professional, collaborative positive relationship with the patient, family, physician(s), and other providers to assess the options for care and use of benefits and community resources.
  12. Maintains appropriate documentation and tracking as required JHM.
  13. Coordinates and identifies high-risk population with a history of poly-pharmacy, to improve quality outcomes with appropriate support services in managing pharmacy needs.
  14. Act as liaison between JHM and JHHC regarding specialty Prior Authorization requests.
  15. Educate matrix partners in regards to JHM health management programs
  16. Represents JHM primary care as a member of a cross-functional project team.

This list is not necessarily an exhaustive list of responsibilities, skills, duties, requirements or working conditions associated with the job. It is intended to be an accurate reflection of the current job; however, management may revise the job and tasks based on business needs including emergencies, staffing needs and workload.


Education: Master’s Degree from an accredited school of nursing / related field required or Bachelor’s degree and currently enrolled in a graduate program with documented plan for program completion.

Knowledge: Demonstrated clinical expertise. Standards of medical practice. Knowledge of health care and managed care delivery systems. Insurance benefit structures and related legal/ medical issues. Quality improvement processes. Community resources. Clinical, satisfaction and financial outcomes.

Skills: Ability to work in a dynamic, team-oriented environment and demonstrate positive relationship building. Effective verbal/ written communication. Ability to affect change. Ability to perform critical analysis, plan and organize effectively. Ability to promote member/family autonomy. Business acumen so that health benefits and member/provider satisfaction are maximized while solidifying the program’s viability through cost effective intervention.

Additionally for Care Manager, Complex: Attitude and skills that facilitate patient engagement in their health care and behavior change.

Required Licensure, Certification, Etc.: Current registered nurse licensure in the state of Maryland. Certification in care management (CCM) preferred.

Work Experience: Minimum eight (8) years clinical practice. Three (3) years care management/ disease management experience in a managed care organization. Experience working with high-risk patients preferred. Experience in project development and working in a matrix environment preferred.


Johns Hopkins Health System and its affiliates are drug-free workplace employers.

Johns Hopkins Health System and its affiliates are an Equal Opportunity / Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.


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