Complex Care Nurse Coordinator in Philadelphia, PA at Public Health Management Corporation

Date Posted: 7/30/2020

Job Snapshot

Job Description

The Complex Care Nurse Coordinator works within the Complex Care Management Team to provide intensive care management for at-risk patients across the PHMC health network. The Complex Care Nurse Coordinator identifies at-risk patients, assesses their health care needs and provides support and education in managing their diagnoses. The Complex Care Nurse Coordinator reports to the Senior Program Manager for Complex Care and seeks to improve health outcomes and treatment compliance for patients through care management and care coordination efforts.


  • Identifies high-risk and complex patients with chronic health conditions and/or complex psychosocial needs
  • Works with the Complex Care Management Team to develop individualized care plans for appropriate patients.
  • Oversees patient care activities, care coordination, and patient engagement in treatment
  • Collaborates with providers and other healthcare team members regarding patient care and progress;
  • Coordinate and manage hospitalized patients’ post-discharge activities and home visits as needed.
  • Utilizes clinical knowledge and EBP to provide clinical support to the team and guide practice.
  • Document all services and contacts in a timely manner in the electronic health record system and other tracking systems
  • Records care provided within electronic medical record and completes other assigned reports.
  • Support the patients with pre-visit checklist process, including assisting the member in preparing for visit, reviewing health maintenance during their visit, placing orders in advance and completing visit follow-up work.
  • Provides outreach in the way of phone call and face to face visits in the home.
  • Works within all state and federal laws and regulations.
  • Notifies immediate supervisor of significant problems.
  • Performs other tasks as directed and needed
  • Maintains positive relationships with funding sources and community organizations.

PHMC Compliance Responsibilities:

  • Understands and adheres to PHMC compliance standards as they appear in the PHMC Code of Conduct, Whistle Blowers and Conflict of Interest Policies.
  • Keeps abreast of all pertinent federal, state and PHMC regulations, laws, and policies as they presently exist and as they change or are modified.
  • Comply with HIPAA and Confidentiality Policies and Procedures as they apply to the job.
  • Comply with Department of Public Health (DPH), The Joint Commission and other accreditation and regulatory agencies standards.
  • Adhere to all PHMC Policies and Procedures.
  • Knowledge and adherence to Infection Control and Environment of Care Guidelines and Procedures as described in the annual education module.

Job Requirements:

  • To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below must be representative of the knowledge, skills, minimum education, training, licensure, experience, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.


  • Ability to adapt to fast paced medical environments and demonstrate flexibility in operating within different work and community settings
  • Ability to use a computer for data entry and tracking; knowledge of Microsoft Excel is a plus
  • Excellent time management skills and attention to detail
  • Excellent oral/written communication skills
  • Ability to maintain client confidentiality
  • Written and oral fluency in English
  • Ability to work with diverse staff in an urban setting
  • Current CPR certification


  • One-year experience as a nurse in primary care, community health and/or behavioral health
  • Case management experience preferred

Education Requirement:

  • BSN Required.
  • Pennsylvania RN License Required

Physical Demands:

  • Position requires standing 2/3 of the time, walking 2/3 of the time, requires sitting under 1/3 of the time, use of hands to finger, handle or feel 2/3 of the time, reach with hands and arms, under 1/3 of the time, stoop, kneel, crouch or crawl under 1/3 of the time, talk or hear over 2/3 of the time. Position requires lifting up to 10 lbs. up to 1/3 of the time.

Work Environment:

  • Moderate noise (examples: business office with computers and printers, light traffic). Travel throughout the Philadelphia area, including visits to patient homes and other facilities. Exposure to blood borne pathogens that requires use of personal protective equipment.


  • Commensurate with education and experience.
  • Pay Grade 21