Job Title: RN Ambulatory Care Coordinator

Employment Type: Full-time

Shift: Day (Remote)
Location: Langhorne, PA

Position Purpose

Serves in an expanded nursing role to collaborate with patients and their Primary Care Providers to provide a model of care that ensures delivery of quality, efficient, and cost-effective healthcare services.  Assesses plans, implements, coordinates, monitors, and evaluates all options and services with the goal of optimizing the patient’s health status.

As a “RN Ambulatory Care Coordinator” you will:

• Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions.
• Outreaches to and enrolls assigned population in care management programs based on care transitions and/or data/predictive models.
• Identifies the targeted population within his/her practice site and risk stratifies all patients to prioritize needs and direct interventions.
• Assesses the healthcare, educational and psychological needs of the patient/family/care giver.           
• Designs an individualized plan of care with the patient and fosters a team approach by working collaboratively with the patient, family/care giver, primary care provider, and other members of the health care team to ensure coordination of services.
• Implements clinical interventions based on risk stratification and evidence-based clinical guideline adherence and promotes best practice by initiating/adjusting therapies as directed by the practitioner.  Provides appropriate follow-up and monitoring as needed to coordinate needed care for the patient.
• Coordinates referrals and other community resources.
• Coordinates care between all care entities through transitions of care: home care, skilled nursing facilities , Acute Rehab, and hospice
• Promotes consistent delivery of quality care: timely access to needed care, patient education, and continuity of care across the continuum. 
• Utilizes appropriate conflict resolution, assertiveness, negotiation, and collaboration skills in facilitating patient care throughout the health care continuum.
• Enhances and promotes the improvement of overall health of the patient and the community utilizing the most cost-effective delivery system.

Minimum Qualifications:

• Must possess a comprehensive knowledge of Clinical Care Coordination and Case Management, as normally obtained through a Bachelor’s degree in Nursing.
• Active Pennsylvania Nursing License in good standing
• Certified Case Manager through CMSA or ACMA preferred with knowledge base in Complex Care Management.
• Valid Driver’s License.
• Must be comfortable operating in a collaborative, shared leadership environment.
• Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health.

[FT/PT Benefit eligible Roles]:

**0.4 FTE (16 hours weekly) up to 1.0 FTE (40 hours weekly)

Position Highlights and Benefits:

• Comprehensive benefit packages, including medical, dental, vision, mental health, paid time off, 403B, education assistance and voluntary benefits (pet insurance, accident insurance, hospital indemnity and others) available from the first day of employment.  
• Work/Life balance with flexible schedules.  
• Free onsite parking.  
• Our mission and core values are what drive each member of Trinity Health to support each other, communicate openly and respectfully while embracing a culture that nurtures a healing, safe environment for all.   
• Referral Rewards Program 

Position Highlights:

• Work/Life balance with flexible schedules.  
• Free onsite parking.  
• Our mission and core values are what drive each member of Trinity Health to support each other, communicate openly and respectfully while embracing a culture that nurtures a healing, safe environment for all.   
• Referral Rewards Program 

St. Mary Medical Center is a beautiful 53-acre state-of-the-art facility comprised of more than 700 physicians, nearly 3,000 colleagues, and 1,100 volunteers committed to providing quality care delivered with compassion and respect.  St. Mary attracts top doctors, introduces cutting-edge technologies and implements advanced procedures to meet the healthcare needs of the people it serves, including the nearly 630,000 residents of Bucks County.