Care Coord RN Pop Health - Administration, CIN

Jefferson Health Plans • Norristown, PA

1d • Onsite

About The Position

As an integral member of the ambulatory care clinical team, the Population Health Care Coordinator RN uses the nursing process to address the physical, psychological, emotional, and social needs of diverse patients served by Ambulatory Clinics. This role involves collaborating, communicating, and coordinating care across various practice settings (home, physician office, hospital, skilled nursing facility) and with primary care providers and support systems. The goal is to provide cost-effective, high-quality healthcare experiences and measurably improve health outcomes, patient experience, and manage costs for identified patient populations. The nurse develops and implements patient-centric care plans based on individual circumstances and environments.

Requirements

• Current licensure as a Registered Nurse in state of employment required.
• 7-10 years of nursing experience.
• Strong command of computer programs including Word, Excel, and PowerPoint.
• Ability to think independently, having received necessary direction, to identify information needed for specific research projects, etc.
• Strong written & verbal communications and organizational skills to make effective action plans needed to deliver meaningful findings on time.
• Ability to work independently on projects to completion.
• Strong attention to detail.

Nice To Haves

• Bachelors Nursing preferred.
• CCM, CMC, or ACM preferred.
• Website development software and Photoshop preferred.

Responsibilities

• Interacts with co-workers, patients, their family/designated care partner(s), and other staff consistent with the values of Jefferson.
• Integrates Evidence-Based Practice, clinical expertise, patients, their family/designated care partner(s) preferences and cultural beliefs and values for delivery of optimal healthcare.
• Partners with patients, their family/designated care partner(s) in identifying learning needs and priorities and provides education in ways that are useful, understandable, and affirming.
• Minimizes risk of harm to patients and others by following established nursing practices and protocols and individual performance.
• Uses information technology to communicate, manage knowledge, mitigate error, and support ethical decision making.
• Develops a tracking system for patient care coordination and care management across the continuum, including care transitions, referrals, report management, and two-way communication between the PCP, specialists, and/or other providers.
• Transitions care for patients discharged from the hospital within 48 hours to prevent readmission and related complications.
• Evaluates and provides appropriate follow-up care for patients seen in the emergency department to prevent further disease exacerbation, untoward complications, or additional ER or hospital utilization.
• Manages complex and high-risk patients identified by transition calls, reports, Provider or team member.
• Maintains timely and ongoing communication with the provider and practice team to maximize the management of patient needs.
• Coordinates care with other care managers (home health care, payer case managers, etc.) and with specialists to maximize care and promote patient safety.

Benefits

• medical (including prescription)
• supplemental insurance
• dental
• vision
• life and AD&D insurance
• short- and long-term disability
• flexible spending accounts
• retirement plans
• tuition assistance
• voluntary benefits
• tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior