Care Coordination RN, Population Health

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 patient populations. They collaborate with various healthcare professionals and support systems to ensure a cost-effective, high-quality healthcare experience.

Responsibilities

• Collaborates with patients, their family/designated care partners, and other staff to deliver optimal healthcare.
• Partners with patients to identify learning needs and priorities, and educates them about their condition, treatments, and recovery.
• Minimizes risks by following established nursing practices and protocols.
• Uses information technology to communicate, manage knowledge, and support ethical decision-making.
• Develops and implements a tracking system for patient care coordination and care management across the continuum.
• Manages complex and high-risk patients identified by transition calls, reports, and provider or team member interactions.
• Communicates timely and ongoing with providers and the practice team to manage patient needs.
• Coordinates care with other care managers, specialists, and case managers to enhance care and promote patient safety.

Requirements

• 7 years of nursing experience.
• Knowledge of evidence-based practice, clinical expertise, and cultural awareness.
• Effective communication skills, including the ability to convey respect and collaborate with patients and families.
• Knowledge of child and adult education techniques and the ability to educate patients and their designated care partners.
• Strong command of computer programs such as Word, Excel, and PowerPoint.
• Ability to work independently and think critically to identify necessary information for specific research projects.
• Strong written and verbal communication skills, along with organizational abilities to develop effective action plans.
• Physical demands include lifting up to 25 lbs., frequent sitting/standing, and keyboard use.

Preferred Qualifications

• Bachelor’s degree in Nursing.
• CCM - Certified Case Manager certification from the Commission for Case Manager Certification.
• CMC - Care Manager Certified from the National Academy of Certified Care Managers.
• ACM - Accredited Case Manager from the American Case Management Association.

Skills

Effective communication, collaboration, and problem-solving skills are essential. The ability to use information technology and manage knowledge is also crucial. Knowledge of health information documentation and the ability to document medical histories, symptoms, vital signs, medications, diagnoses, treatment plans, procedures, and medical results are important.

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. Additionally, Jefferson provides access to tuition discounts for eligible colleagues, including those who work less than part-time.