Care Coordinator Manager - Northern Medical Associat - TB - Acute Philadelphia

Thomas Jefferson University & Jefferson Health
United States, Pennsylvania, Philadelphia
Mar 28, 2025
Job Details Primary Function: Manager will oversee the operations of the CPC/IDC/Pride care coordination team, in addition to supporting practices and providers as a care coordinator. Coordinates the care for the practices' high-risk patients served to promote preventive/wellness/ education for high risk patients with chronic diseases in the outpatient environment to meet the practice and enterprise care coordination goals and metrics. Coordinates the smooth transition of care for cohort of high-risk patients between inpatient and outpatient arenas in order to prevent readmission to the hospital Collaborate with Jefferson Enterprise population health team so that efforts are aligned with other primary care practices in the pursuit of quality related incentives Oversee the work of the RN clinical care coordinator(s) and work, in conjunction with the Practice Operations Manager to coordinate activities and responsibilities of the Outreach Coordinator(s), Community Health Worker(s) as it pertains to population health initiatives and evidence-based care. Assist in the development, implementation and oversight of the Urban Health Initiative program. Will develop/write grant and research proposal focused on community based programs to address the social determinants of health. Will seek opportunities to partners with community organizations, centers faith-based communities that recognize barriers to clinical and other resources. Oversee the program as it relates to staff; client recruitment; outcomes; data collection; management of budgets, billing, and timelines; model fidelity; and coordination of training. Will work with program staff to develop and implement individual case-management plans for clients participating in the program, and will collect and report data on program outcomes and efficacy and actively engage in continuous quality improvement. Oversee, and participate in, routine nursing care for a primary care population Ensure staff adheres to regulatory protocols. Ensure proper documentation is kept and reported as necessary to regulatory bodies. Collaborate closely with an interdisciplinary team within the Einstein Healthcare Network. Outreach and education to both the Healthcare Network and the larger community regarding the program. Set clear goals for the team and provide consistent leadership in attaining them; will work to maintain high staff motivation and morale; and, most importantly, will ensure that excellent clinical care is consistently delivered. This position requires providing service to the following age population(s) 18+ for primary clients; all ages for client families in a manner that demonstrates an understanding of the functional/developmental age of the individual served. Job Description Education/Training/Experience: RN Degree with at least 3 years of hands-on clinical experience in primary care required, 5 years of experience in this capacity preferred. Greater than 3 years of management experience preferred. Experience in population health quality improvement preferred. Licenses/Certifications: Active PA license Work Shift Workday Day (United States of America) Worker Sub Type Regular Primary Location Address 5501 Old York Road, Philadelphia, Pennsylvania, United States of America 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.