Job Summary

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.

Job Duties

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.

Position Details

Our Primary Care RN Coordinators (PCNC) work within our Community Practice sites across the Geisinger territory. In total, there are presently 39 sites where our PCNCs provide support. On a typical day, our RN Coordinators will do adult wellness visits, transition of care calls, assist the provider(s) in answering appropriate messages, take care of normal lab values, place orders for follow-ups, place referrals, and more. The RN Coordinator will assist with office procedures such as IV, wound care teaching, education to the LPN staff, and patient education.

Our primary goal is to improve the health outcomes of our patients.

• Hours: 8 am to 4:30 pm (no weekends, holidays or on-call)
• Travel: Limited for meetings, orientation/training
• Required experience: 2 years of RN work experience

Geisinger cares about not only its patients and members but also about you and your family. We offer a competitive compensation and benefits package to ensure that you and your loved ones can maintain good health, achieve financial stability, and excel both personally and professionally. We believe in creating a diverse and inclusive environment where all employees can be their authentic selves. To learn more: https://jobs.geisinger.org/diversity 

Benefits of working at Geisinger: 

• Full benefits (health, dental and vision) starting on day one 
• Three medical plan choices, including an expanded network for out-of-area employees and dependents  
• Pre-tax savings plans with healthcare and dependent care flexible spending accounts (FSA) and a health savings account (HSA)  
• Company-paid life insurance, short-term disability, and long-term disability coverage  
• 401(k) plan that includes automatic Geisinger contributions  
• Generous paid time off (PTO) plan that allows you to accrue time quickly  
• Up to $5,000 in tuition reimbursement per calendar year  
• MyHealth Rewards wellness program to improve your health while earning a financial incentive  
• Family-friendly support including adoption and fertility assistance, parental leave pay, military leave pay and a free Care.com membership with discounted backup care for your loved ones  
• Employee Assistance Program (EAP): Referrals for childcare, eldercare, & pet care. Access free legal guidance, mental health visits, work-life support, digital self-help tools and more.  
• Voluntary benefits including accident, critical illness, hospital indemnity insurance, identity theft protection, universal life and pet and legal insurance  

Education

Graduate from Specialty Training Program-Nursing (Required), Bachelor's Degree-Nursing (Preferred)

Experience

Minimum of 2 years-Nursing (Required)

Certification(s) and License(s)

Basic Life Support Certification - Default Issuing Body; Licensed Registered Nurse (Pennsylvania) - RN_State of Pennsylvania

About Geisinger

Founded more than 100 years ago by Abigail Geisinger, the system now includes ten hospital campuses, a 550,000-member health plan, two research centers and the Geisinger Commonwealth School of Medicine. With nearly 24,000 employees and more than 1,700 employed physicians, Geisinger boosts its hometown economies in Pennsylvania by billions of dollars annually. Learn more at geisinger.org or connect with us on Facebook, Instagram, LinkedIn and Twitter.

Our Commitment to Diversity, Equity and Inclusion

Geisinger values who you are, where you are from, and where you are going. We seek out people of various backgrounds and cultures with unique abilities, non-traditional career paths and ambitious aspirations. 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. Read more about Our Commitment to Inclusive Recruiting.

Our Vision & Values

Everything we do is about making better health easier 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.

Our Benefits

We offer healthcare benefits for full time and part time positions from day one, including vision, dental and prescription coverage.