Population Care Coordinator

Capital Health (US); Lawrenceville (NJ); On-site; USD 87,000 - 114,000; Full time

Benefits offered by this job

Medical Plan

Dental Plan

Vision Plan

FSA

Retirement Savings and Investment Plan

Paid Time-Off Program

Job summary

Capital Health is seeking a Population Care Coordinator (RN) to work within a multidisciplinary primary care team. You will focus on high‑risk and complex patients, coordinating care and ensuring adherence to plans across primary and specialty care and external services.

You will utilize EMR systems, participate in team meetings, and drive preventative and chronic care processes while traveling between practices as needed.

Qualifications

• Bachelor's Degree in Nursing (RN) and NJ/PA license.
• Five years of clinical experience in acute care, rehab, sub-acute, home care, managed health plan, or outpatient setting.

Responsibilities

• Coordinate identified patient care with primary and specialty care teams.
• Monitor transitions of care after hospital admissions and ER visits.
• Follow up to ensure comprehensive assessments and adherence to care plans.
• Utilize EMR/registries to prioritize follow-up and track metrics.
• Coach patients to ensure access to medications and services as instructed.

Skills

Coaching

Interpersonal skills

Motivational interviewing

Data analysis

Education

Bachelor's Degree in Nursing

Tools

EMR/registries

Job description

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 - $113,630.40

Scheduled Weekly Hours

40

Position Overview

SUMMARY (Basic Purpose of the Job)

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.

Minimum Requirements

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

Essential Functions

• 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 patients to ensure they are aware of instructions, has necessary prescriptions, access to medications and services, and what to look for regarding adverse events as per their care givers instructions.
• Works with care teams to identify high-risk, high-need patients by helping to implement best practice processes for preventative services, chronic care and disease management.
• Uses screening tools to select and track performance of identified patients, metrics and clinical outcomes.
• Performs audits on identified performance and quality metrics.
• Attends required training and collaboration sessions as scheduled.
• Performs other duties as assigned.

PHYSICAL DEMANDS AND WORK ENVIRONMENT

• Frequent physical demands include: Sitting , Twisting , Reaching forward
• Occasional physical demands include: Standing , Walking , Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Bending , Reaching overhead , Squat/kneel/crawl
• Continuous physical demands include: Wrist position deviation , Pinching/fine motor activities , Keyboard use/repetitive motion , Talk or Hear
• Lifting Floor to Waist 25 lbs. Lifting Waist Level and Above 15 lbs
• Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Color Discrimination, Accurate Depth Perception, Accurate Hearing
• Anticipated Occupational Exposure Risks Include the following: N/A

This Position Is Eligible For The Following 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
• Disability Benefits – Long Term Disability (LTD)
• Disability Benefits – Short Term Disability (STD)
• Employee Assistance Program
• Commuter Transit
• Commuter Parking
• Supplemental Life Insurance
• Voluntary Life Spouse
• Voluntary Life Employee
• Voluntary Life Child
• Voluntary Legal Services
• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance
• Voluntary Identity Theft Insurance
• Voluntary Pet Insurance
• Paid Time-Off Program

The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level.

The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.