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Care Coord RN Pop Health (Day shift, 40hrs/week)

Jefferson Health Plans•Abington Township, PA
•Onsite

About The Position

The Population Health Care Coordinator RN uses the nursing process to provide patient- and family-centered care that respects each person’s uniqueness and addresses physical, psychological, emotional, and social needs. As part of the ambulatory clinical team, the nurse collaborates, communicates, and coordinates care across settings—including the home, physician office, hospital, and skilled nursing facility—with primary care providers, support systems, and other care team members. The role supports cost-effective, high-quality care and develops and implements individualized plans based on each patient’s circumstances and environment. The approach is patient-centric and intended to improve health and care experience while managing costs for an identified patient population. The nurse coordinates transitions, referrals, report management, and communication among primary care providers, specialists, and other providers. The role includes timely follow-up after hospital discharge and emergency department visits, management of complex and high-risk patients, ongoing communication with providers and practice teams, and coordination with other care managers and specialists.

Requirements

  • Seven years of nursing experience.
  • Knowledge of patient- and family-centered practice, including showing respect and collaborating with patients, families, and designated care partners in care and care planning.
  • Cultural awareness and ability to connect effectively and respectfully with people from diverse backgrounds.
  • Effective communication skills, including conveying, receiving, and accurately interpreting information and needs; engaging patients and families as partners; and delegating respectfully and appropriately.
  • Knowledge of child and adult education techniques and ability to identify learning needs and educate patients and designated care partners about conditions, treatment, medications, and recovery steps.
  • Knowledge of health information and documentation methods, including recording histories, symptoms, vital signs, medications, diagnoses, treatment plans, procedures, tests, and results in written or electronic form.
  • Current Pennsylvania Registered Nurse license.
  • Current New Jersey Registered Nurse license.

Nice To Haves

  • Bachelor’s degree in Nursing.
  • Strong command of computer programs including Word, Excel, and PowerPoint.
  • Website development software and Photoshop experience.
  • Ability to think independently, with appropriate direction, and identify information needed for research projects.
  • Strong written and verbal communication and organizational skills to create effective action plans and deliver findings on time.
  • Ability to work independently on projects through completion.
  • Strong attention to detail.
  • Certified Case Manager (CCM) certification from the Commission for Case Manager Certification.
  • Care Manager Certified (CMC) credential from the National Academy of Certified Care Managers.
  • Accredited Case Manager (ACM) credential from the American Case Management Association.

Responsibilities

  • Interact with co-workers, patients, family members or designated care partners, and other staff in accordance with Jefferson’s values.
  • Integrate evidence-based practice, clinical expertise, and patient and family preferences and cultural beliefs into care.
  • Partner with patients and their designated care partners to identify learning needs and provide understandable, useful education.
  • Follow established nursing practices and protocols to minimize risk of harm to patients and others.
  • Use information technology to communicate, manage knowledge, mitigate errors, and support ethical decision-making.
  • Develop a system for tracking care coordination and care management across the continuum, including transitions, referrals, report management, and two-way communication among primary care providers, specialists, and other providers.
  • Coordinate transition care for patients discharged from the hospital within 48 hours to help prevent readmission and related complications.
  • Evaluate and arrange appropriate follow-up for patients seen in the emergency department to help prevent disease exacerbation, complications, and additional emergency department or hospital utilization.
  • Manage complex and high-risk patients identified through transition calls, reports, providers, or team members.
  • Communicate with providers and practice teams in a timely and ongoing manner to maximize management of patient needs.
  • Coordinate care with other care managers, including home health and payer case managers, and with specialists to maximize care and promote patient safety.

Benefits

  • Medical and prescription insurance
  • Supplemental insurance
  • Dental insurance
  • Vision insurance
  • Life and AD&D insurance
  • Short- and long-term disability insurance
  • Flexible spending accounts
  • Retirement plans
  • Tuition assistance
  • Voluntary benefits, including access to group insurance rates and discounts
  • Tuition discounts at Thomas Jefferson University after one year of full-time service or two years of part-time service
  • Medical and prescription insurance access for all colleagues, including those working less than part-time

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