Population Care Coordinator

Work Shift: Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advance technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region. Position Overview: Population Care Coordinator JOB CODE:40301 FLSA Exemption Status:Exempt SUMMARY (BASIC PURPOSE OF THE JOB) 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 depending on office location (New Jersey or 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 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. Requires travel to various practices on a routine basis. 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 Usual Work Day:8 Hours REPORTING RELATIONSHIPS Does this position formally supervise employees? No If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager. ESSENTIAL FUNCTIONS Ensures identified patient care is coordinated with primary care, specialty care and outside agencies (ie. home care, rehabilitation, community resources etc). Monitors transition of care phone calls and visits for patients following hospital admissions and emergency room visits. Monitors that 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). Utilizes 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. Lifting Waist Level and Above 15 lbs. Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Color Discrimination, Accurate Depth Perception, Accurate Hearing Anticipated Occupational Exposure Risks Include the following: N/A Offers are contingent upon successful completion of our onboarding process and pre-employment physical. Capital Health will require all applicants to have an annual flu vaccine prior to start date, with the exception of individuals with medical and religious exemptions. "Company will never ask candidates for social security numbers or date of birth during application phase. If you are asked for this information online, you may be a target for identity theft." Welcome to Capital Health's new career opportunity page. Here you will have access to view and apply to career opportunities in our hospital and physician practice locations. Equal Opportunity Employer Notice Capital Health Benefits