Population Care Coordinator

Position Overview

The Population Care Coordinator (PCC) works on a multidisciplinary health care team in a primary care setting to understand the needs of patients in the population and to address identified care gaps. Recognizes profiles for physicians and patients ranging from limited intervention to complex needs. Focuses on coaching and coordination of care for identified patients and works alongside physicians, advanced care providers and office staff, focusing on identifying the needs of high risk and clinically complex patients, while assisting the practices in developing processes for managing patient populations. Promotes patient-centric care and actively participates in multidisciplinary patient-centered team meetings.

Minimum Requirements

• Education: Bachelor's Degree in Nursing
• Valid Registered Nurse license New Jersey and Pennsylvania
• Experience: Five years clinical experience in acute care, rehabilitation, sub acute, home care, managed health plan, or outpatient setting. Utilization review and/or discharge planning experience preferred
• Other Credentials: AHA BLS - Healthcare Provider, Registered Nurse - NJ, Registered Nurse - PA
• Knowledge and Skills: Familiarity with community resources and social service resources; strong PC skills with experience navigating multiple electronic documentation systems; data analysis skills; highly developed interpersonal skills, including motivational interviewing. Is innovative in how to approach the population and able to work with leadership to design and implement programs.
• Special Training: Case Management, Ambulatory Care, Care Coordination, or other relevant certification preferred. Must complete an identified care coordination education program within six months of hire.

Mental, Behavioral and Emotional Abilities

• Demonstrated ability to influence others while motivating them to change
• Multitasking and prioritization while working in a high-volume environment
• Working independently, as well as with teams

Essential Functions

• Ensures identified patient care is coordinated with primary care, specialty care and outside agencies (ie. home care, rehabilitation, community resources etc)
• Makes sure transition of care phone calls and visits for patients following hospital admissions and emergency room visits are monitored
• Makes sure appropriate services are in place and are being delivered as directed by the care team
• Conducts follow-up to ensure that initial patient assessment and post-visit consultation includes a comprehensive medical, psychosocial and functional assessment of the patients identified for tracking and monitors identified care team patients to ensure adherence to the plan of care, screenings, and treatment goals (including self-management goals)
• Uses EMR/registries to prioritize patient follow-up, tracks follow-up visits with appropriate specialists, and tracks and reviews completeness of testing for identified complex patients (to includes chronic and acute measures)
• Coaches and communicates with identified patients to ensure they are aware of instructions, has necessary prescriptions, access to medications and services, and what to look for regarding adverse events as per their care givers instructions
• Works with care teams to identify high-risk, high-need patients by helping to implement best practice processes for preventative services, chronic care and disease management
• Uses screening tools to select and track performance of identified patients, metrics and clinical outcomes
• Performs audits on identified performance and quality metrics
• Attends required training and collaboration sessions as scheduled
• Performs other duties as assigned

Physical Demands and Work Environment

• Frequent physical demands include: Sitting, Twisting, Reaching forward
• Occasional physical demands include: Standing, Walking, Climbing (e.g., stairs or ladders), Carry objects, Push/Pull, Bending, Reaching overhead, Squat/kneel/crawl
• Continuous physical demands include: Wrist position deviation, Pinching/fine motor activities, Keyboard use/repetitive motion, Talk or Hear
• Lifting: Floor to Waist 25 lbs, Waist Level and Above 15 lbs

Sensory Requirements

• Accurate Near Vision, Accurate Far Vision, Color Discrimination, Accurate Depth Perception, Accurate Hearing

Anticipated Occupational Exposure Risks

• N/A

This Position Is Eligible For The Following Benefits

• Medical Plan
• Prescription drug coverage & In-House Employee Pharmacy
• Dental Plan
• Vision Plan
• Flexible Spending Account (FSA)
• Healthcare FSA
• Dependent Care FSA
• Retail Savings and Investment Plan
• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance
• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance
• Disability Benefits – Long Term Disability (LTD)
• Disability Benefits – Short Term Disability (STD)
• Employee Assistance Program
• Commuter Transit
• Commuter Parking
• Supplemental Life Insurance
• Voluntary Life Spouse
• Voluntary Life Employee
• Voluntary Legal Services
• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance
• Voluntary Identity Theft Insurance
• Voluntary Pet Insurance
• Paid Time-Off Program