Care Coordinator (Full Time) Day Shift, Bustleton and Veree 8/14/2019

Thomas Jefferson University & Jefferson Health Philadelphia, PA

Philadelphia, PA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Bachelors Degree


Collaborate, communicate and coordinate care for patients and populations across the care continuum (home, physician office, hospital, skilled nursing facility)
Collaborate with primary care providers, support systems and care teams to provide a model of care that ensures the delivery of a cost-effective high quality delivery of 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, experience of care and 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 1) transitioning to or from home and community-based health care 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, and 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 may be time spent in Transitions of Care work, or Longitudinal Care Coordination, or combination of both.
Collaborate with payors in the identification and assessment of high risk patients to determine care coordination needs. Provide feedback to payors via reports or presentation of cases on high utilization patients.

For this position, it is a requirement that you are fluent in Russian.

Educational / Training Requirements
Degree/Diploma Obtained Program of Study Required/Preferred
Bachelors 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. Pennsylvania
Valid Drivers License
CCM, CMC, or ACM preferred.
Experience Requirements
Years of Experience Type of Experience
Experience Requirements

- 7 - 10 years clinical experience required; with 2 or more years of Case Management/Discharge
Planning/Disease Management experience preferred.

- Prior Case Management, Disease Management or Home Care experience preferred. Primary care experience a plus

- Understanding of CPC+, Understanding of Population Health core tenets desirable

- Familiar with HEDIS/CGCAHPS quality and experience of care measures/methods, Knowledgeable of age-specific developmental issues and aware of resources to assist patients and practices.

- Must be able to effectively engage and communicate with patients/families, physicians and other healthcare professionals in a professional manner.

- Must be able to maintain confidentiality of patient information, be
a patient advocate, be collaborative and above to delegate when appropriate. Knowledgeable of
Insurance and managed care regulations. Computer proficiency required.

Jefferson Health delivers state of the art healthcare services to patients throughout the Delaware Valley and southern New Jersey. Jefferson (Philadelphia University + Thomas Jefferson University) provides more than 8,400 students from nearly 40 states and 40 countries with 21st century professional education. Combined, we have 30,000 employees.

Jefferson Health, with 14 hospitals (seven are Magnet designated by the ANCC for nursing excellence) and 40+ outpatient and urgent care locations, offers a broad range of primary and complex, highly specialized care that touches the lives of more than four million patients annually. U.S. News & World Report has ranked Thomas Jefferson University Hospital among the nation's best in 10 specialties. Jefferson Health also includes the NCI designated Sidney Kimmel Cancer Center; it is one of only 70 such centers in the nation.

Jefferson (Philadelphia University + Thomas Jefferson University) has ten colleges and three schools that offer more than 160 undergraduate and graduate programs. Our University is dedicated to inter-professional and transdisciplinary approaches to learning that offer a vibrant and expandable platform for professional education. Through this unique model, we are preparing our students for current and yet to be imagined careers.

As an employer, the Jefferson Enterprise maintains 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.