Care Coordination LPN, Population Health

Job Details

Job Description

With a commitment to patient- and family-centered care, the Population Health Care Coordinator LPN 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 and 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.
• Oversight of the care coordination system for medium and high risk patients that is managed by the practice team.

Work Shift

Worker Sub Type

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 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's 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 8,300 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.