Full-time (80 hours biweekly)

Monday through Friday: 8 am - 4:30 pm

Patient population- complex pediatrics

The RN in Population Health within Ambulatory Care Management plays a critical role in improving outcomes and care continuity for complex pediatric patients within the Women’s & Children’s service line. This role focuses on care coordination, patient and family education, and collaboration with multidisciplinary teams across ambulatory and acute care settings in York County and surrounding areas. The RN is responsible for proactively managing clinical needs to support optimal health and reduce avoidable healthcare utilization.

General Summary

Coordinates and monitors the health needs of patients under value-based care risk arrangements, such as pain, symptom management, behavioral health, DME's, home health, assistance with daily living, and/or community resources. This position works closely with patients, caregivers, family members, physicians, hospital care managers, and ancillary service providers to achieve the patient's maximum functional potential. This position provides on-going support through comprehensive assessment and care planning. This position ensures patient's cases are in compliance with regulatory guidelines.

This position will:

• Serve as the primary clinical coordinator for complex pediatric patients receiving care across ambulatory, specialty, and hospital-based settings.
• Develop, implement, and monitor individualized care plans in partnership with families, pediatricians, specialists, case management, social work, and community partners.
• Identify barriers to care, facilitate timely access to services, and ensure appropriate follow-up post-discharge, ED visits, or specialty interventions.
• Participate in case conferences and multidisciplinary rounds as needed to support wraparound services and seamless transitions of care.
• Utilize population health tools, EHR alerts, and analytics to identify high-risk pediatric patients requiring active care management.
• Provide patient/family education focused on chronic disease self-management, medication adherence, and preventive care.
• Collaborate with social services, behavioral health, home care agencies, and school health to align and coordinate care across systems.
• Maintain accurate, timely documentation and communication in the electronic medical record.

Remote Work Capable: more than 50% from home

Essential Functions:

• Utilizes Motivational Interviewing as a patient-centered technique to promote self-management of chronic conditions and improve long-term outcomes.
• Maintains a caseload of patients per department guidelines and conducts outreach according to established protocols.
• Engages patients in home, primary care offices, and other community settings as appropriate.
• Identifies, enrolls, and manages patients in Complex Care Management programs.
• Conducts Transitions of Care and proactive outreach for high-risk patients and ensures appropriate follow-up via care management, or technology.
• Develops, implements, and updates individualized care plans to optimize health outcomes and promote wellness.
• Performs medication review and uses teach-back methods to confirm patient understanding and adherence.
• Collaborates with PCPs, specialists, and hospitalists to coordinate and implement patient-centered care plans.
• Initiates and tracks referrals to internal services and community resources to support care goals.
• Provides resource management to ensure the right care is delivered at the right time and place, optimizing cost and experience.
• Assists patients in navigating personal health decisions and care preferences, including but not limited to Advance Care Planning, to ensure individualized support and goal-aligned care.
• Documents assessments, care plans, goals, and interventions in the electronic health record per accrediting body and departmental standards.

Common Expectations:

• Prepares and maintains appropriate documentation as required, while maintaining established policies and procedures, objectives, quality assessment and safety standards.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
• Attends meetings as required.

Travel Requirements:

• Estimated Amount: 10% - Travel required. Makes home visits.