Care Coord RN Pop Health (FT-Day, 40hrsweek) TJU, Administration

Job Details

Job Description

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.

Essential Functions

• 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.

Work Shift

Worker Sub Type

Employee Entity

Primary Location Address

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 65000 people strong dedicated to providing the highest-quality compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrows 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 8300 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 diemcolleagues adjunct faculty and Jeff Temps) have access to medical (including prescription) insurance.

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