About this role
- Provides care coordination by collaborating with a multidisciplinary team.
- Promotes patient adherence to individualized plan of care.
- Collaborates and communicates patient findings to primary care provider, Care Coordination Team, and healthcare providers, and identified care-partner(s) as appropriate across various health care settings via timely, accurate, and clear communication modalities.
- Applies specific payer clinical guidelines as applicable.
- Utilizes evidence-based risk-stratification tools to proactively assess chronically-ill population, identify patients at risk for disease-related sequelae and deliver patient-centered evidence-based interventions to prevent future progression or exacerbation of illness. During exacerbation, intervenes at the
earliest opportunity through multidisciplinary collaboration with all members of the care team, including patient and identified care-partner to return the patient safely to optimal level of health/function in an optimal setting. Identifies opportunities for health promotion and disease prevention. Identifies Social/Behavioral Health needs which impact patient goals and refers to Social Work team member for support/co-management as deemed appropriate. Assess/Refer patients to available community support services as deemed necessary. Collaborates with multidisciplinary team to develop innovative strategies addressing the needs of the population.
- Assesses the self-care needs of the high-risk patient and identifies need for additional support. Provides patient/care-partner(s) education regarding prevention/ recognition/ treatment of disease exacerbation and promotes self-management of chronic condition and comorbidities. Coordinates care with the patient's primary provider and providers outreach and education as applicable
and under the direction of the provider.
- Maintains patient confidentiality with all activities in the Care Coordination Program.
- Attends payer webinars as applicable to the patient population. Downloads and utilizes payer reports to identify patients for outreach. Assists in orientation and training of new staff as requested. Participates in provider outreach and education. Serves as a community resource, providing educational programs for the community.
- Assumes responsibility and accountability for professional development and
pursues ongoing continuing education in order to deliver patient-centered care.
Demonstrates successful completion of ongoing proficiency and compliance
with regulatory requirements.
- Collaborates with ACO leadership on additional tasks as requested.
Required:
- Graduate of an accredited Nursing Program; BSN required
- Current NJ Registered Professional Nursing license required.
- Current PA and NY Nursing license a plus.
- Minimum 5 years of clinical experience as a Registered Professional Nurse.
Preferred:
- Community health experience and knowledge of community healthcare resources preferred
- CCM certification preferred.
Other:
- Strong clinical, interpersonal, analytical, priority setting, problem solving, and organizational skills.
- Ability to work with minimum direct supervision.
- Ability to navigate EHR and data bases with demonstrated ability for electronic
clinical documentation.
- Clear and accurate verbal, telephonic, and written communication skills.