Care Coord RN Pop Health (FT-Day, 40hrs/week) - Administration

Thomas Jefferson University•Abington, 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. The role involves collaborating, communicating, and coordinating care for patients and populations across various settings (home, physician office, hospital, skilled nursing facility) with primary care providers, support systems, and the care team. The goal is to ensure a cost-effective, high-quality healthcare experience by developing and implementing patient-centric care plans that measurably improve health, enhance the patient experience, and reduce/manage costs for identified patient populations.

Requirements

7 years Nursing experience
Patient-and Family-Centered Practice Knowledge of how to convey respect and collaborate with each patient, family and/or designated care partner in care and care planning.
Cultural Awareness Knowledge of people with diverse backgrounds and the ability to convey respect and connect effectively.
Effective Communication Understanding of effective communication concepts, tools and techniques, ability to effectively transmit, receive, and accurately interpret ideas, information, and needs through the application of appropriate communication behaviors. Uses the language of partnership with patients and families, engaging them in their health and health care. Appropriately and respectfully delegates to other team members.
Patient and Designated Care Partner Education Knowledge of child and adult education techniques and the ability to elicit learning priorities and needs and educate patients and their designated care partners on the patient's condition, the treatment and medications suggested and given, and the next steps in the patient's recovery.
Health Information Documentation Knowledge of the relevance of health information and appropriate documentation methods, ability to record medical histories, symptoms, vital signs, medications, diagnoses, treatment plans, procedures, tests, and medical results in written or electronic form.
RN - Licensed Registered Nurse_PA - State of Pennsylvania
RN - Licensed Registered Nurse_NJ - State of New Jersey

Nice To Haves

Bachelor’s Degree Nursing
Strong command of computer programs including Word, Excel, and PowerPoint.
Website development software and Photoshop preferred.
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.
CCM - Certified Case Manager - Commission for Case Manager Certification
CMC - Care Manager Certified - National Academy of Certified Care Managers
ACM - Accredited Case Manager - American Case Management Association

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.
Development of 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.
Transition care for patients discharged from the hospital within 48 hours to prevent readmission and related complications.
Evaluation of and appropriate follow-up care for patients seen in the emergency department to prevent further disease exacerbation, untoward complications, or additional ER or hospital utilization.
Management of complex and high risk patients identified by transition calls, reports, Provider or team member.
Timely and ongoing communication with the provider and practice team to maximize the management of patient needs.
Coordination of care with other care managers (home health care, payer case managers, etc.) and with specialists to maximize care and promote patient safety.