Ambulatory Care RN Pop Health​/Chronic Care

Ambulatory Care RN Population Health/Chronic Care

Regular Full-Time
Brandywine, MD, US

6 days ago Requisition

Salary Range: $90,000.00 To $98,000.00 Annually

Reports To: Ambulatory Care Nurse Manager

Date Revised: October 2025, June 2026

Greater Baden Medical Services (GBMS) is a Federally Qualified Health Center (FQHC) dedicated to providing high-quality healthcare across Southern Maryland. With 9 clinical sites across Prince George's, Charles, and St. Mary's counties, we serve over 18,000 patients each year. We provide fully integrated care that includes primary care, pediatrics, women's health, Title X family planning, dental care, behavioral health, WIC, pharmacy services, and the Ryan White HIV/AIDS program.

Our patient population is primarily made up of Medicaid and uninsured individuals. We are deeply proud to deliver these vital services to everyone in our community, regardless of their ability to pay, making Greater Baden an incredibly rewarding place to grow your career while making a tangible, life‑changing impact every day.

Job Summary:

The Ambulatory Care RN Population Health/Chronic Care Manager plays a essential role in improving patient outcomes, reducing hospital readmissions, and advancing preventive care through strategic care coordination and remote patient monitoring. This position supports key initiatives such as chronic care management and the Patient‑Centered Medical Home (PCMH), while serving as a clinical resource for safe, efficient, and responsive care delivery.

Essential Job Functions:

• Utilizes the nursing process to provide care management services to identify at‑risk patients by supporting patient self‑management of disease and behavior modification interventions.
• Understands PCMH concepts and supports PCMH initiatives related to care management.
• Maintains the volume of care management patients and care plans needed to meet PCMH requirements.
• Conducts patient education classes related to Diabetes Prevention, Diabetes Self‑Management, and Obesity.
• Manages and coordinates care for patients with chronic diseases and contributes to population health initiatives.
• Monitors avoidable ER visits for each MCO and reaches out to patients to determine reason for ER visit. Provides patient education on best way to utilize medical services.
• Assists coordination of post‑discharge follow‑up appointments and needed medication and supplies.
• Coaches patients and family in follow‑up to chronic health conditions and self‑management strategies presented during hospitalization and planned clinic/health care provider visits.
• Assists the Population Health Manager in identifying and mitigating gaps in care.
• Educates non‑adherent patients on the importance of closing care gaps and monitors patients for compliance.
• Builds and maintains positive working relationships with patients, family members, providers, case managers, and other health agency representatives.
• Continuously expands knowledge and understanding of community resources, services, and programs.
• Provides triage service in person or over the telephone.
• Provides health teaching and counseling to patients and families. This may include communicating test results, medication changes, etc.
• Provides direct nursing care to patients, including performing assessments, nursing procedures (including injections), and assistance with procedures.
• Offers medication reconciliation and adherence counseling while assessing patient knowledge and addressing barriers to adherence and self‑care.
• Assesses patient requests for same‑day services and works with Providers and Center Manager to ensure patient needs are addressed appropriately.
• Expedites patient flow through the implementation of standing orders or policies for medication refills, referrals, and immunizations. Ensures that clinical medical assistants are familiar with standing order protocols and follow them appropriately.
• Participates in the immunization process, including inventory and record keeping. Ensures that vaccines are stored properly. Oversees immunization administration process and educates staff regarding proper technique and current recommendations. Has knowledge of the Vaccines For Children program…