Care Coord RN Pop Health (FT-Day ,40 hrs/week) - CIN CPC+

About the role

The Population Health Care Coordinator RN at Ambulatory Clinics works in a patient- and family-centered care environment, using the nursing process to address the physical, psychological, emotional, and social needs of diverse patients. This role requires collaboration with patients, their families, and other healthcare professionals to ensure high-quality, cost-effective healthcare.

Responsibilities

• Collaborate with patients, their families, and other healthcare professionals to develop and implement a care plan that meets the unique needs of each patient.
• Use evidence-based practice and clinical expertise to provide care that respects and incorporates the preferences and cultural beliefs of patients and their families.
• Educate patients and their families about their health conditions, treatments, and medications.
• Manage complex and high-risk patients, ensuring timely communication with providers and care teams to coordinate care.
• Coordinate care with other care managers, specialists, and payers to improve patient outcomes and reduce costs.
• Develop and maintain a tracking system for patient care coordination and care management across the continuum, including care transitions and referrals.
• Assist in transition care for patients discharged from the hospital within 48 hours to prevent readmissions and related complications.
• Evaluate patients seen in the emergency department to prevent further disease exacerbation, complications, or additional ER or hospital utilization.

Requirements

• Bachelor’s Degree in Nursing
• Required 7 years of nursing experience

Qualifications

• Patient-and Family-Centered Practice Knowledge
• Cultural Awareness
• Effective Communication Skills
• Health Information Documentation Knowledge
• Strong Command of Computer Programs (Word, Excel, PowerPoint)
• Ability to Think Independently and Work Thoroughly
• Attention to Detail

Skills

• Strong Written & Verbal Communications Skills
• Organizational Skills
• Independent Project Completion

Benefits

Jefferson offers a comprehensive package of benefits, including medical, dental, vision, life, and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, and voluntary benefits. Jefferson is committed to providing equal educational and employment opportunities for all individuals.