Population Care Coordinator

This is a fully remote position, open to applicants in New Jersey, +1 more state.

📋 Description

• Collaborate with a multidisciplinary healthcare team in a primary care environment to assess population needs and address identified gaps in care.

• Coach and manage care for designated patients, with a focus on high-risk and clinically complex individuals.

• Partner with physicians, advanced care providers, and office personnel.

• Assist practices in establishing processes for managing patient populations effectively.

• Advocate for patient-centered care and engage in multidisciplinary team meetings focused on patient-centered approaches.

• Coordinate care for patients with primary care, specialty care, and external agencies as needed.

• Oversee transition-of-care phone calls and visits following hospital admissions and emergency room visits.

• Ensure that appropriate services are provided and delivered as directed by the care team.

• Conduct follow-ups to guarantee comprehensive medical, psychosocial, and functional assessments.

• Monitor patients for adherence to care plans, screenings, and treatment objectives.

• Utilize EMR/registries to prioritize follow-ups and track the completion of specialist visits and tests.

• Coach and inform patients regarding instructions, prescriptions, medications, services, and potential adverse events.

• Assist care teams in identifying high-risk, high-need patients and implementing best-practice processes.

• Employ screening tools to select and monitor patient performance, metrics, and clinical outcomes.

• Conduct audits on performance and quality metrics.

• Attend mandatory training and collaboration sessions.

• Perform other assigned duties as necessary.

⛳️ Requirements

• Bachelor's Degree in Nursing.

• Valid Registered Nurse license in New Jersey and Pennsylvania.

• Minimum of five years of clinical experience in acute care, rehabilitation, subacute, home care, managed health plans, or outpatient settings.

• Experience in utilization review and/or discharge planning is preferred.

• AHA BLS - Healthcare Provider certification.

• Registered Nurse certification for NJ.

• Registered Nurse certification for PA.

• Knowledge of community resources and social service resources.

• Strong computer skills with experience in navigating various electronic documentation systems.

• Proficient in data analysis.

• Highly developed interpersonal skills, including expertise in motivational interviewing.

• Ability to collaborate with leadership to design and implement programs.

• Willingness to travel to various practices on a regular basis.

• Case Management, Ambulatory Care, Care Coordination, or other relevant certification is preferred.

• Completion of an identified care coordination education program is required within six months of hire.

• Proven ability to influence and motivate others to change.

• Capability to multitask and prioritize effectively in a high-volume environment.

• Ability to work both independently and as part of a team.

🏝️ Benefits

• Medical Plan.

• Prescription drug coverage & In-House Employee Pharmacy.

• Dental Plan.

• Vision Plan.

• Flexible Spending Account (FSA).

• Healthcare FSA.

• Dependent Care FSA.

• Retirement Savings and Investment Plan.

• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance.

• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance.

• Long Term Disability (LTD) benefits.

• Short Term Disability (STD) benefits.

• Employee Assistance Program.

• Commuter Transit benefits.

• Commuter Parking benefits.

• Supplemental Life Insurance.

• Voluntary Life Insurance for Spouse.

• Voluntary Life Insurance for Employee.

• Voluntary Life Insurance for Child.

• Voluntary Legal Services.

• Voluntary Accident, Critical Illness, and Hospital Indemnity Insurance.

• Voluntary Identity Theft Insurance.

• Voluntary Pet Insurance.

• Paid Time-Off Program.