Population Care Coordinator

About Cooper University Health Care

Cooper University Health Care is a leading academic health system affiliated with Cooper Medical School of Rowan University. Cooper, headquartered in Camden, New Jersey, has revenues of more than $3 billion and an A+ credit rating from both S&P and Fitch Ratings.

Cooper has nearly 14,000 team members, including more than 2,200 nurses, more than 1,200 employed physicians representing 95 specialties and subspecialties, and more than 700 advanced practice providers.

Cooper operates MD Anderson Cancer Center at Cooper as well as three hospitals – its 663-bed flagship Cooper University Hospital in Camden, its 229-bed Cooper University Hospital Cape Regional in Cape May Court House, and Children’s Regional Hospital in Camden.

Cooper University Hospital in Camden is the only Level 1 trauma center in South Jersey and the busiest in the region. The hospital has been recognized as a top-performing regional hospital by U.S. News & World Report’s Best Hospitals annual survey for six years.

More than 2.54 million patients visit Cooper’s facilities annually. Cooper’s ambulatory network encompasses three outpatient surgery centers, seven urgent care centers, a wound care center, and more than 130 physician, physical therapy, and radiology offices extending from the Delaware River to the New Jersey shore.

Cooper was named one of America’s Best Large Employers for 2026 by Forbes, ranking among the top 200 in the nation.

Visit CooperHealth.org to learn more.

Support and participates in the Patient-centered Medical Home (PCMH) concepts of care coordination and team- based care. Assess, plan, implement, coordinate, monitor and evaluate healthcare options and services with the goal of increasing the likelihood of improvement to the health status of identified populations across the continuum. • Follow established PCC workflow for utilization and self-management support • Participate in PCMH activities which include but are not limited to: hospital discharge follow-up, care planning, coordination of services, and communication between care providers • Collaborate with patient’s medical/health and community-based providers to establish mutual goal-setting including patients and their families/caregivers, utilizing self-management tools. • Provide outreach, care management and education for disease self-management per patient centered goals. 

Support and participates in the Patient-centered Medical Home (PCMH) concepts of care coordination and team- based care. 
Assess, plan, implement, coordinate, monitor and evaluate healthcare options and services with the goal of increasing the likelihood of improvement to the health status of identified populations across the continuum. 
•    Follow established PCC workflow for utilization and self-management support
•    Participate in PCMH activities which include but are not limited to: hospital discharge follow-up, care planning, coordination of services, and communication between care providers
•    Collaborate with patient’s medical/health and community-based providers to establish mutual goal-setting including patients and their families/caregivers, utilizing self-management tools. 
•    Provide outreach, care management and education for disease self-management per patient centered goals.
•    Identify, document, and mitigate patient barriers to improved outcomes.
•    Monitor and evaluate the services and community based resources necessary to respond to the individual member’s health needs. 
•    Provides telephonic and or in-practice outreach, disease management and/or case management, education, and other clinically based activities for target populations.
•    Conduct assessments, develop nursing treatment plans and interventions and set goals for treatment plans/behavioral modifications within the scope of licensure in collaboration with other care providers.
•    Assists physicians and other team members in developing and implementing evidence based practices and care plans for target health populations. 
•    Collect data on quality metrics and track as required for improvement efforts.
•    Participate in process/quality improvement initiatives to achieve targets as defined by organizational/department goals and objectives.

5 years or more clinical experience, Experience in primary care, population or case management preferred

Current NJ RN License