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

With a commitment to patient- and family-centered care, 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. As an integral member of the ambulatory care clinical team, the nurse collaborates, communicates, and coordinates care for patients and populations across practice settings (home, physician office, hospital, skilled nursing facility) and with primary care providers, support systems, and the care team to deliver cost-effective, high-quality healthcare.

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, and patient/family preferences and cultural beliefs for optimal healthcare delivery.
• Partners with patients and their family/designated care partner(s) to identify learning needs and provides education in useful, understandable, and affirming ways.
• Minimizes risk of harm by following established nursing practices, protocols, and individual performance standards.
• 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 PCPs, specialists, and other providers.
• Transitions care for patients discharged from the hospital within 48 hours to prevent readmission and related complications.
• Evaluates and provides follow-up care for patients seen in the emergency department to prevent further disease exacerbation, complications, or additional ER/hospital utilization.
• Manages complex and high-risk patients identified through transition calls, reports, or provider/team referrals.
• Ensures timely and ongoing communication with providers and practice teams to maximize patient needs management.
• Coordinates care with other care managers (home health, payer case managers, etc.) and specialists to promote patient safety.

Requirements

• 7 years of nursing experience.
• Patient- and Family-Centered Practice: Knowledge of how to convey respect and collaborate with patients, families, and designated care partners in care planning.
• Cultural Awareness: Ability to connect effectively with people from diverse backgrounds.
• Effective Communication: Understanding of communication concepts, tools, and techniques to transmit, receive, and interpret ideas and needs; uses partnership language with patients and families.
• Patient and Designated Care Partner Education: Knowledge of child and adult education techniques to elicit learning priorities and educate on conditions, treatments, medications, and recovery steps.
• Health Information Documentation: Ability to record medical histories, symptoms, vital signs, medications, diagnoses, treatment plans, procedures, and test results accurately.
• Active RN license in Pennsylvania and/or New Jersey.

Qualifications

• Bachelor’s Degree in Nursing (preferred).
• Strong command of computer programs including Word, Excel, and PowerPoint.
• Experience with website development software and Photoshop (preferred).
• Ability to think independently, identify information needs, and conduct research projects.
• Strong written, verbal, and organizational skills to deliver meaningful findings on time.
• Ability to work independently and complete projects with strong attention to detail.
• Certifications (preferred):
  • 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).

Benefits

• Comprehensive package including medical (with prescription coverage), dental, vision, life, and AD&D insurance.
• Short- and long-term disability coverage.
• Flexible spending accounts.
• Retirement plans.
• Tuition assistance and discounts at Thomas Jefferson University after one year of full-time service or two years of part-time service.
• Voluntary benefits providing group rates and discounts.
• All colleagues, including part-time and per diem, have access to medical (including prescription) insurance.

Physical Demands

• Lift and carry up to 25 lbs.
• Frequent sitting, standing, and keyboard use.
• May require kneeling, bending, squatting, and performing CPR as part of patient care duties.

Work Shift: Day shift (United States of America).