Care Coordination RN, Population Health

Job Details

With a commitment to patient- and family-centered care, the Population Health Care Coordinator RN uses the nursing process in ways that values the uniqueness of each individual and addresses the physical, psychological, emotional, and social needs of the diversity of patients served by Ambulatory Clinics. As an integral member of the of the ambulatory care clinical team, the nurse effectively collaborates, communicates and coordinates care for patients and populations across each practice setting (home, physician office, hospital, skilled nursing facility) and with primary care providers, support systems and care team to provide a model of care that ensures the delivery of a cost-effective high quality healthcare experience. Develops and implements a plan of care for each individual based upon the context of that person and their environment. Ensures approach is patient-centric, and measurably improves health, experience of care and reduces/manages cost for an identified patient population.

Job Description

Summary
With a commitment to patient- and family-centered care, the Population Health Care Coordinator RN uses the nursing process in ways that values the uniqueness of each individual and addresses the physical, psychological, emotional, and social needs of the diversity of patients served by Ambulatory Clinics. As an integral member of the of the ambulatory care clinical team, the nurse effectively collaborates, communicates and coordinates care for patients and populations across each practice setting (home, physician office, hospital, skilled nursing facility) and with primary care providers, support systems and care team to provide a model of care that ensures the delivery of a cost-effective high quality healthcare experience. Develops and implements a plan of care for each individual based upon the context of that person and their environment. Ensures approach is patient-centric, and measurably improves health, experience of care and reduces/manages cost for an identified patient population.

Job Duties

• 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, patients, their family/designated care partner(s) preferences and cultural beliefs and values for delivery of optimal healthcare.
• Partners with patients, their family/designated care partner(s)) in identifying learning needs and priorities and provides education in ways that are useful, understandable, and affirming.
• Minimizes risk of harm to patients and others by following established nursing practices and protocols and individual performance.
• Uses information technology to communicate, manage knowledge, mitigate error, and support ethical decision making.
• Development of a tracking system for patient care coordination and care management across the continuum, including care transitions, referrals, report management, and two-way communication between the PCP, specialists, and/or other providers.
• Transition care for patients discharged from the hospital within 48 hours to prevent readmission and related complications.
• Evaluation of and appropriate follow-up care for patients seen in the emergency department to prevent further disease exacerbation, untoward complications, or additional ER or hospital utilization.
• Management of complex and high risk patients identified by transition calls, reports, Provider or team member
• Timely and ongoing communication with the provider and practice team to maximize the management of patient needs
• Coordination of care with other care managers (home health care, payer case managers, etc.) and with specialists to maximize care and promote patient safety.

Minimum Qualifications

• 7 years Nursing experience
• Patient-and Family-Centered Practice
• Knowledge of how to convey respect and collaborate with each patient, family and/or designated care partner in care and care planning.
• Cultural Awareness
• Knowledge of people with diverse backgrounds and the ability to convey respect and connect effectively.
• Effective Communication
• Understanding of effective communication concepts, tools and techniques, ability to effectively transmit, receive, and accurately interpret ideas, information, and needs through the application of appropriate communication behaviors. Uses the language of partnership with patients and families, engaging them in their health and health care. Appropriately and respectfully delegates to other team members.
• Patient and Designated Care Partner Education
• Knowledge of child and adult education techniques and the ability to elicit learning priorities and needs and educate patients and their designated care partners on the patient's condition, the treatment and medications suggested and given, and the next steps in the patient's recovery.
• Health Information Documentation
• Knowledge of the relevance of health information and appropriate documentation methods, ability to record medical histories, symptoms, vital signs, medications, diagnoses, treatment plans, procedures, tests, and medical results in written or electronic form.
• RN - Licensed Registered Nurse_PA - State of Pennsylvania
• RN - Licensed Registered Nurse_NJ - State of New Jersey

Preferred Qualifications

• Bachelor’s Degree Nursing
• Strong command of computer programs including Word, Excel, and PowerPoint.
• Website development software and Photoshop preferred.
• Ability to think independently, having received necessary direction, to identify information needed for specific research projects, etc.
• Strong written & verbal communications and organizational skills to make effective action plans needed to deliver meaningful findings on time.
• Ability to work independently on projects to completion
• Strong attention to detail.
• 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

Physical Demands
Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.

Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Albert Einstein Medical Center

Primary Location Address

5501 Old York Road, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.    

Jefferson is committed to providing equal educa­tional and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status. 

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

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