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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.

Minimum Education:

+ Associate's degree required

+ Bachelor's degree preferred

Work Experience:

+ 3 years Nursing experience required

+ Experience in Care Management or Clinical Nursing specialty preferred; Minimum of 3 years of clinical experience in pediatrics, NICU, PICU, or pediatric care management

Licenses:

+ Licensed Registered Nurse Upon Hire Required or

+ Registered Nurse Multi State License Upon Hire Required and

+ Basic Life Support Upon Hire Required

Courses and Training:

+ Residency in service area. Upon Hire Preferred

Knowledge, Skills, and Abilities:

+ Excellent communication and interpersonal skills.

+ Proficient in SBAR technique.

+ Ability to effectively present clinical information to the care team.

+ Proven organizational and motivational skills.

+ Ability to work cooperatively as part of a team.

+ Self-motivated and dependable.

+ Able to work independently.

WellSpan Health's vision is to reimagine healthcare through the delivery of comprehensive, equitable health and wellness solutions throughout our continuum of care. As an integrated delivery system focused on leading in value-based care, we encompass more than 2,300 employed providers, 250 locations, nine award-winning hospitals, home care and a behavioral health organization serving central Pennsylvania and northern Maryland. Our high-performing Medicare Accountable Care Organization (ACO) is the region's largest and one of the best in the nation. With a team 23,000 strong, WellSpan experts provide a range of services, from wellness and employer services solutions to advanced care for complex medical and behavioral conditions. Our clinically integrated network of 3,000 aligned physicians and advanced practice providers is dedicated to providing the highest quality and safety, inspiring our patients and communities to be their healthiest.

Quality of Life. Founded in 1741, the city of York is considered by many as the first capital of the United States. The Articles of Confederation were signed by the Second Continental Congress here in 1777. Its beautifully restored historic district is an architectural treasure. While York retains its farming and manufacturing heritage, at its heart York is a thriving cultural community that has attracted creative talent and innovative entrepreneurial investors from across the nation. Life in York County offers affordable housing, options for higher education, a thriving arts and cultural community, historical attractions, parks and recreational resources, semi-professional baseball team, fine dining and more - within an easy drive of major East Coast cities. York County residents can find local employment in healthcare, manufacturing, technology, agricultural and service sectors. (Patient population: 445,000)

WellSpan Health is an Equal Opportunity Employer. It is the policy and intention of the System to maintain consistent and equal treatment toward applicants and employees of all job classifications without regard to age, sex, race, color, religion, sexual orientation, gender identity, transgender status, national origin, ancestry, veteran status, disability, or any other legally protected characteristic.