Job Description

Facility: Valleywise Health Medical Center

Department: Ambulatory Care Management

Schedule: Regular FT 40 Hours Per Week

Shifts: Days

Under the direction of the Director Care Management/Manager, the RN Population Care Coordinator works autonomously and is accountable for identifying, stratifying and addressing the needs of high risk populations in ambulatory services. This position assumes a leadership role, and works collaboratively with the patient, family and as part of the interdisciplinary team to evaluate the quality of health in both populations and individuals and possess the knowledge to implement evidence-based care standards to obtain satisfactory outcomes in selected patient populations.  Additionally, this position is responsible for anticipating, monitoring and intervening as indicated to address population health needs across the continuum of health care in order to improve quality and maintain standards set by Center for Medicare and Medicaid Services (CMS) and through the National Committee for Quality Assurance (NCQA) in the Patient-Centered Medical Home (PCMH) model.  The modalities utilized by the RN Population Care Coordinator across the care continuum with a focus on quality outcomes can include health risk management, complex care and disease management, health promotion, wellness, preventative services, care coordination of community health resource referrals, behavioral health referrals, patient education, development of self-management and advance care planning when applicable and advocacy.





  • Prefer a Bachelor's degree or higher in Nursing.


  • Must have a minimum of three (3) years of progressively responsible acute clinical experience that demonstrates an understanding of the required knowledge, skills and abilities.
  • Prefer one (1) year of experience in ambulatory nursing or equivalent and/or experience with patient-centered medical home model.

Specialized Training:

  • None


  • Must possess a current,valid AZ RN license, temporary AZ RN license or valid compact RN licensure for current state of practice.  Must also be in good standing with the issuing Board of Nursing.
  • Care Coordination Transition Management (CCTM) or Case Management (CM) or equivalent certification is preferred.

Knowledge, Skills & Abilities:

  • Must be able to demonstrate knowledge of ambulatory disease states, preventative and wellness management practices and pathways, HEDIS criteria, Valleywise Health policy and procedures, and regulatory standards ensuring high quality and safe standards of care.
  • Must exhibit competency in Microsoft Office software programs and other software systems once trained.
  • Required to possess analytic skills to support data and trend evaluation.
  • Must be a self-starter, demonstrate self-direction and work independently with minimal supervision.
  • Expected to multitask and work in a fast paced setting.
  • Must demonstrate professionalism, team work, critical thinking skills and serve as a professional role model.
  • Essential to possess excellent customer service and phone skills with the ability to communicate well, build rapport and collaborate with patients, internal and external clients in order to meet quality outcome goals.
  • Demonstrated computer literacy required with basic to intermediate knowledge of Microsoft Office applications including Word, Excel and Powerpoint.
  • Experience with databases is preferred.
  • Must be able to read, write and speak effectively in English.

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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