Population Care Coordinator

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 advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than
600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization.

As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates.

The listed pay range or pay rate reflects compensation for a
full-time equivalent (1.0 FTE)position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

Pay Range:

$86,528.00 - $

Scheduled Weekly

Hours:

40

Position Overview

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.

Education: Bachelor’s Degree in Nursing. Valid Registered Nurse license New Jersey and 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,Registered Nurse - PA

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

• 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…