Today, Jefferson Health and its network of hospitals and physician practices serve patients throughout the Delaware Valley. We have a robust network of 18 hospitals, 3500 physicians, 9600 nurses, 3,876 licensed beds, and physician practices throughout the counties of:

• Bucks
• Camden
• Gloucester
• Montgomery
• Philadelphia

We are Philadelphia#39;s second largest employer, and nationally ranked by US News amp; World Report in seven specialties including #2 Ophthalmology (Wills Eye), #9 Rehabilitation (MossRehab), #10 in Orthopedics (Rothman Orthopaedics at Jefferson Health, Philadelphia Hand to Shoulder Center, 3B Orthopedics, the Abington Orthopedic amp; Spine). Whether yoursquo;re in the city or the suburbs, Jefferson Health provides the exceptional care you expect ndash; close to home or work ndash; through our broad family of primary care physicians and specialists. Jefferson Health is home to nationally ranked experts who provide a personalized care plan for you. Sidney Kimmel Cancer Center ndash; Jefferson Health is one of only 70 NCI-designated cancer centers in the country. With more than 30,000 employees, we are the largest health system in the Philadelphia region by total licensed beds. And our work to improve lives is never done.

In keeping with Jefferson#39;s Mission, We Improve Lives, it is our goal to recruit, retain, develop and reward highly-qualified employees. If you are enthusiastic, caring and dedicated to service excellence, we invite you to consider joining Jefferson. Jefferson encourages its employees to expand their knowledge and develop their careers through growth opportunities and continuing education.

Culture

We are a creative and collaborative team dedicated to outstanding professional work on behalf of our patients. Our goal is to meet our patients#39; needs and help them advocate for themselves and their family members. We believe our place in the community is as a healer, an activist, and a trusted friend. We perform our duties with empathy and compassion as we serve the needs of the underserved population of North Philadelphia. While we do have an academic component to our work, we strive to be community doctors who take pride in serving others. Join us...make a difference.

Job 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.

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.

Competencies (Knowledge, Skills, and Abilities Required):
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.

OUR MISSION: We improve lives.
OUR VISION: Reimagining health, education amp; discovery to create unparalleled value.
OUR VALUES: Put People First, Be Bold amp; Think Differently, Do the Right Thing.

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#39;s condition, the treatment and medications suggested and given, and the next steps in the patient#39;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.

Minimum Education and Experience Requirements:

Education:
Current licensure as a Registered Nurse in state of employment required. Bachelors Nursing preferred.

AND

Experience:
7-10 years of nursing experience

Minimum Certifications, Registration or License Requirements:
CCM, CMC, or ACM preferred.

Additional Information
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 amp; 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.

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 finger print based federal criminal records check. The selected candidate will not be allowed to commence working until all three (3) are completed satisfactorily.

Jefferson includes Thomas Jefferson University and Jefferson Health, a dynamic university and health system with broad reach across the Delaware Valley. Jefferson is the second largest employer in Philadelphia and the largest health system in Philadelphia based on total licensed beds.

Through the merger of Thomas Jefferson University and Philadelphia University in 2017, our University includes ten colleges and four schools. We are an NCAA Division II university and an R2 national doctoral university offering undergraduate and graduate-level programs that provide students with a forward-thinking education in architecture, business, design, engineering, fashion and textiles, health, medicine and social science.

Jefferson Health, the clinical arm of Thomas Jefferson University, has grown from a three-hospital academic health center in 2015, to an 18-hospital health system through mergers and combinations that include hospitals at Abington Health, Aria Health, Kennedy Health, Magee Rehabilitation and Einstein Healthcare Network. We have over 50 outpatient and urgent care centers; ten Magnetreg;-designated hospitals (recognized by the ANCC for nursing excellence); the NCI-designated Sidney Kimmel Cancer Center (one of only 70 in the country and one of only two in the region); and one of the largest faculty-based telehealth networks in the country. In 2021, Jefferson Health became the sole owner of HealthPartners Plan, a not-for-profit health maintenance organization in Southeastern Pennsylvania. We are the first health system regionally to create an aligned payer-provider partnership.

Jeffersonrsquo;s mission, vision and values create an organization that attracts the best and the brightest students, faculty, staff, and healthcare professionals, as well as the most visionary leaders to drive exceptional results.

• OUR MISSION: We improve lives.
• OUR VISION: Reimagining health, education and discovery to create unparalleled value
• OUR VALUES: Put People First, Be Bold amp; Think Differently and Do the Right Thing

As an employer, Jeffersonmaintains a commitment to provide equal access to employment. Jefferson values diversity and encourages applications from women, members of minority groups, LGBTQ individuals, disabled individuals, and veterans.