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

Jefferson Health Plans • Philadelphia, PA

20h

About The Position

With a commitment to patient- and family-centered care, the Population Health Care Coordinator RN uses the nursing process in ways that values the uniqueness of each individual and addresses the physical, psychological, emotional, and social needs of the diversity of patients served by Ambulatory Clinics. As an integral member of the of the ambulatory care clinical team, the nurse effectively collaborates, communicates and coordinates care for patients and populations across each practice setting (home, physician office, hospital, skilled nursing facility) and with primary care providers, support systems and care team to provide a model of care that ensures the delivery of a cost-effective high quality healthcare experience. Develops and implements a plan of care for each individual based upon the context of that person and their environment. Ensures approach is patient-centric, and measurably improves health, experience of care and reduces/manages cost for an identified patient population.

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.
• 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.

Benefits

• Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts.
• Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service.
• All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 501-1,000 employees