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ACO-Cin Care Coordinator

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Job ID: 214512
Category: Clinical Support
Work Type: FT
Location: Plainsboro, NJ, United States
Work Schedule: FT

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Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.

Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?


  • The registered nurse/care coordinator will work on a multidisciplinary healthcare team in a primary care setting. The RN will focus on coaching and coordination of care for Princeton Medicine (PM) participating patients. The RN will work alongside the physicians and office staff focusing on identifying the needs of PM’s complex members. This person will promote patient-centered care, work side-by-side with primary care providers and medical home team members, and actively participate in multi-disciplinary patient-centered team meetings. The RN is a key role in the Patient Centered Medical Home program.


  • Care Transitions Coaching and Coordination- Work with hospital case managers, discharge planners and emergency room contact to engage these entities in relevant case management activities with each member of the practice to ensure all necessary post discharge needs are met. Through telephonic contact, face to face office visits and/or home visits ensure care is coordinated with home care providers, specialists or other resources as needed Ensure follow up primary care visits are obtained within 48 hours of ER visit or hospital discharge. Conduct follow-up to ensure that initial patient assessment and post-visit consultation includes a comprehensive medical, psychological and functional assessment are all completed as identified by the patient-centered medical home. Track follow –up visits with appropriate specialists for complex patients Communicate with and coach patients to ensure they are aware of discharge instructions, have necessary prescriptions, access to medications, and understand how to take necessary medications, including what to look for regarding adverse events. Monitor that appropriate home care, hospice care, and other ancillary services (DME, infusion services , etc.) are in place and are being delivered as directed by the care team. Facilitate and confirm that timely communication between physicians and the home are professionals is occurring. Coordinate necessary referrals and authorizations with care management areas. Facilitate the information flow between hospital, long-term care, specialists, home health representatives and the care team. Work with physicians, office staff and nurse practitioners to help identify high risk, high need, and high utilization patients. Assist physicians and others on care team in implementing processes for best practices for preventive services, chronic care and disease management. Utilize EMR/Chronic disease registry reporting to prioritize patient follow-up. Work collaboratively with physicians and the care team to ensure patient adherence to medical plan of care, including all appropriate preventive and disease specific screenings, interventions, treatment goals-including self-management goals. Determine that screening tests are up-t-date; review test results and take action on abnormal testing. Verify that all members are receiving appropriate screening and behavioral health interventions.


  • Registered Nurse - NJ (Required)

Education or Equivalent Experience:

● Associate's degree in nursing - required
● Bachelor's degree in nursing (BSN) - preferred

    We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.

    Live Your Life's Work

    We are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.

       Current UPHS employees must apply HERE
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