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 the diverse patient population served by Ambulatory Clinics. As an integral member of the ambulatory care clinical team, the nurse collaborates, communicates, and coordinates care for patients 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 to deliver optimal healthcare.
• Partners with patients and their family/designated care partner(s) to identify learning needs, providing education in useful, understandable, and affirming ways.
• Minimizes risk of harm to patients and others by following established nursing practices and protocols.
• 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 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 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 the practice team to maximize patient care.
• 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 engage patients and families in their health and care.
• Patient and Designated Care Partner Education: Knowledge of child and adult education techniques to address learning priorities and needs.
• Health Information Documentation: Ability to record medical histories, symptoms, treatments, and test results accurately in written or electronic form.
• Active RN license in Pennsylvania and/or New Jersey.

Preferred Qualifications

• Bachelor’s Degree in Nursing.
• Strong command of computer programs including Word, Excel, and PowerPoint; familiarity with website development software and Photoshop preferred.
• Ability to work independently, think critically, and identify information needs for research projects.
• Strong written, verbal, and organizational skills to deliver actionable findings on time.
• Strong attention to detail.
• Certifications: CCM (Certified Case Manager), CMC (Care Manager Certified), or ACM (Accredited Case Manager).

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.

Schedule

Workday Day shift.

Benefits

Jefferson offers a comprehensive benefits package for full-time and part-time colleagues, including:

• Medical (including prescription), dental, and vision insurance.
• Supplemental insurance (life, AD&D, short- and long-term disability).
• 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 access to group rates and discounts.

All colleagues, including those working less than part-time (per diem, adjunct faculty, Jeff Temps), have access to medical insurance.