Serves in an expanded nursing role as part of an interdisciplinary team to promote preventative patient care, offer screening services, and coordinate disease management services while also providing primary clinical support to the provider, patient and their family to assist in the diagnosis and treatment of the patient's condition. Assists clinic team with triage of in basket messaging as needed and management of patient interaction with the clinic identifying patient needs, intervention pathways, clinical guidelines and diagnostic tests to develop individualized plans of care.
The Primary Care Nurse Coordinator performs Medicare Annual Wellness Visits to support wellness planning and management of chronic disease. Also provides education visits including diabetic education and other chronic disease education for populations identified through wellness visits, patient registries or by the clinic provider.
Actively outreaches to clinic patient's post-hospital discharge for Transitions of Care coordination.
Assesses the healthcare, educational and psychosocial needs of the patient/family and involves them in establishing a treatment plan based on realistic goals and interventions.
Investigates healthcare options and facilitates communication among the patient, primary care provider and other members of the healthcare team to eliminate barriers and identify interventions for treatment.
Applies age-appropriate learning principles to educate patients, family and other health care members on the role and purpose of Care Coordination, its processes, disease/case management programs and outcomes
Serves as a resource to patients, families and other healthcare team members regarding disease management.
Implements clinical interventions based on risk stratification and evidence-based clinical guidelines.
Collaborates with primary care providers to enhance evidence-based clinical guideline adherence and promote best practice by initiating/adjusting therapies as directed by the practitioner and providing appropriate follow-up and monitoring as needed.
Coordinates laboratory and diagnostic tests for all disease management programs.
Collaborates with primary care providers to enhance evidence-based clinical guideline adherence and promote best practice by initiating/adjusting therapies as directed by the practitioner and providing appropriate follow-up and monitoring as needed. Facilitates/coordinates laboratory and diagnostic tests for all disease management programs.
Maintains required documentation in EPIC for all disease management activities. Collects and enters data and patient information according to department standards.
Attends and participates in professional and nursing continuing education programs and exploits professional development opportunities.
Reviews the current literature regarding effective teaching/learning strategies and disease management strategies and incorporates the appropriate techniques into disease management practice.
Maintains active involvement in post-discharge Transitions of Care coordination.
Assists leadership in the design, implementation and evaluation of care coordination programs to support overall CPSL goals and strategic business strategies.
Collects and prepares laboratory specimens (blood, urine, sputum, wound secretions) and completes associated paperwork (request slips, lab log, container labels, billing documents) to expedite laboratory studies with maximum accuracy and efficiency.
Inserts, monitors, regulates and discontinues IV's as required by provider and per scope of practice.
Administers medications and vaccines, including intradermal/skin testing, under the direction of a provider and per scope of practice.
Performs other duties as required or assigned.
Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.
Hours:Monday through Friday;Shifts will be between 8AM and 4:30PM
Travel: Less than 50% for meetings, training or coverage
At Geisinger, the caring that we provide to our patients and members also extends to you and your family. Our competitive compensation and benefits package helps you and your loved ones stay healthy, meet your financial goals and thrive professionally and personally.
Benefits: Geisinger offers a comprehensive suite of healthcare benefits, including medical, prescription drug, vision and dental coverage. And with our healthcare benefits, you'll also receive care from one of the top innovative healthcare systems in the country. Our suite of benefits supports you and your family in a variety of ways, including coverage for same-sex or opposite-sex spouses, domestic partners and their children and stepchildren.
Paid Time Off:Our generous paid-time-off packages allow you to take the time you need to travel, rest, and care for and reconnect with friends and family. We also offer paid military and parental leave.
Diversity and Inclusion:We strive to create an environment where our patients, health plan members and employees can be their most authentic selves. Join one of our many Employee Resource Groups (ERGs). ERGs provide opportunities for all Geisinger employees to build internal and external networks and further develop professionally. ERGs are formed around common identities but are open to all employees.
Tuition Assistance: Up to $5,000 tuition reimbursement: We offer tuition reimbursement towards both undergraduate and graduate degrees.(Part time and Full Time Positions only)
Graduate from Specialty Training Program-Nursing (Required), Bachelor's Degree-Nursing (Preferred)
Minimum of 5 years-Clinical (Required)
Certification(s) and License(s)
Licensed Registered Nurse (Pennsylvania) - RN_State of Pennsylvania; Basic Life Support Certification - Default Issuing Body
OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation. SAFETY: We provide a safe environment for our patients and members and the Geisinger family We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. We know that a diverse workforce with unique experiences and backgrounds makes our team stronger. Our patients, members and community come from a wide variety of backgrounds, and it takes a diverse workforce to make better health easier for all. We are proud to be an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran.
We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
At Geisinger, our innovative ideas are inspired by the communities we serve – like our Fresh FoodFarmacy, a program that delivers life-saving healthy alternatives to patients with diabetes. With additional tools like our MyCode Community Health Initiative, one of the first health system genome sequencingprograms, and our new asthma app suite that we developed in partnership with AstraZeneca, it’s no wonder we’re ranked one of the Top 5 Most Innovative Healthcare Systems by Becker's Hospital Review. We continually work towards continuous improvement in a culture where everyone has a voice and firmly believe that better begins with all of us.Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 1...3 hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers. What you do at Geisinger shapes the future of health and improves lives – for our patients, communities, and you.