Benefits Overview

Beyond a great professional environment, Abington – Jefferson Health offers a competitive compensation and benefits package to full and part-time employees. A few highlights include medical, dental, sick time, vacation and holiday specialty certifications, discount parking, direct deposit, credit union, on-site childcare and more!

View more details.

Job #9244924
Registered Nurse Care Coordinator
Comprehensive Primary Care Plus
Full-Time - Days - 40 Hours/Week
Abington Hospital - Jefferson Health
1200 Old York Road, Abington, PA 19001
Primary Responsibilities:
  • Collaborates, communicates and coordinates care for patients and populations across the care continuum (home, physician office, hospital, skilled nursing facility).
  • Collaborates with primary care providers, support systems and care teams to provide a model of care that ensures the delivery of cost-effective and high-quality care.
  • 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 and experience of care. Reduces/manages cost for an identified patient population.
  • Collaborates with inpatient and outpatient care teams and other members of the care coordination team to improve the health of the patient with a focus on those who are most at risk for health deterioration, sentinel events and/or poor outcomes.
  • Core components of the Jefferson Care Coordination Model include the Longitudinal Care Coordination program and Transitions of Care program. The Transitions of Care program will target those patients who are transitioning to or from home and community-based healthcare facilities for acute care services (hospital or emergency department), rehabilitation services, skilled nursing services or other community-based services.
  • Longitudinal Care Coordination will target those patients attributed to a Jefferson or Jefferson-affiliated primary care or specialty practice that may have multiple chronic diseases, unmanaged disease severity, poor self-care, poly-pharmacy, high utilization rates or other factors contributing to poor health, or those identified by clinicians at potential high risk for health deterioration.
  • The Care Coordinator responsibilities will largely include these core functions with a balance between the two that will vary depending on the needs of the population and the care team. At times, the needs of the population may dictate a high proportion of the coordinator’s time may be spent in Transitions of Care work, Longitudinal Care Coordination, or combination of both.
  • Collaborates with payors in the identification and assessment of high-risk patients to determine care coordination needs. Provides feedback to payors via reports or presentation of cases on high-utilization patients.

Qualifications

Educational/Training Requirements

Degree/Diploma Obtained Program of Study Required/Preferred:
  • Bachelor's in Nursing required.

Additional Training Requirements:
  • Maintains good communication with hospital personnel and physicians regarding issues of practice and role.
  • Ability to work in multiple geographic locations in keeping within the schedule.

Licensing Requirements

Certificates/Licenses/Registration – State:
  • Current licensure as a Registered Nurse. Pursues learning opportunities to maintain certification.
  • Valid Pennsylvania driver's license.
  • CCM, CMC or ACM preferred.

Experience Requirements

Years of Experience/Type of Experience:
  • 7-10 years of clinical experience required with 2 or more years of case management/discharge planning/disease management experience preferred.
  • Case management, disease management or home care experience preferred.
  • Primary care experience a plus.
  • Understanding of CPC+.
  • Understanding of Population Health core tenets desirable.
  • Familiarity with HEDIS/CGCAHPS quality and experience of care measures/methods.
  • Knowledge of age-specific developmental issues and aware of resources to assist patients and practices.

Conditions of Employment:
Since this position will require the selected candidate to engage in regular contact with children in the form of care, guidance, supervision or training, you will be required to meet the requirements of the Child Protective Services Act, including the Pennsylvania State Police criminal background check, the Pennsylvania Department of Welfare child abuse criminal background clearance, and an FBI fingerprint-based federal criminal records check. The selected candidate will not be allowed to commence working until all three (3) are completed satisfactorily.
Abington Hospital – Jefferson Health is an equal opportunity employer, and our policy prohibits discrimination in employment because of race, creed, national or ethnic origin, gender, sexual orientation, age, disability, marital status, or veteran status.
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Benefits Overview

Beyond a great professional environment, Abington – Jefferson Health offers a competitive compensation and benefits package to full and part-time employees. A few highlights include medical, dental, sick time, vacation and holiday specialty certifications, discount parking, direct deposit, credit union, on-site childcare and more!

View more details.

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