Partnership Health is hiring a RN Care Coordinator in Somerset, NJ to work in collaboration and continuous partnership with chronically ill or “high-risk” patients and their family/caregiver(s), clinic/hospital/specialty providers and staff, and community resources in a team approach.
Position is Monday - Friday 9-5 or 8-4
Summary of Duties:
- Assists chronically ill and “high-risk” patients through the healthcare system by acting as a patient advocate and navigator.
- Participates in Patient-Centered Medical Home team meetings and quality improvement initiatives.
- Facilitates health and disease patient education, including leading group office visits.
- Works with patients to plan and monitor care:
- Assess patient’s unmet health and social needs
- Develop a care plan with the patient, family/caregiver(s) and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate)
- Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed
- Create ongoing processes for patient and family/caregiver(s) to determine and request the level of care coordination support they desire at any given point in time
- Facilitate patient access to appropriate medical and specialty providers
- Educate patient and family/caregiver(s) about relevant community resources
- Facilitate and attend meetings between patient, family/caregiver(s), care team, payers, and community resources, as needed
- Supports patient self-management of disease and behavior modification interventions.
- Coordinates continuity of patient care with external healthcare organizations and facilities, including the process hospital admission and discharge and referrals from the primary care provider to a specialty care provider.
- Coordinates continuity of patient care with patients and families following hospital admission, discharge, and ER visits.
- Manages high risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting, including a registry.
- Conducts comprehensive, preventive screenings for patients and/or assists all support staff in daily patient interactions as needed.
- Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
- Facilitates patient medication management based upon standing orders and protocols.
- Participates on a team for data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to the Patient-Centered Medical Home and Medical Neighborhood initiatives.
- Evaluates clinical care, utilization of resources, and development of new clinical tools, forms, and procedures.
- Serves as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources
- Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals
- Assist with the identification of “high-risk” patients (the chronically ill and those with special health care needs), and add these to the patient registry (or flag in EHR)
- Attend Care Coordinator training courses/webinars and meetings
- Provide feedback for the improvement of the Care Coordination Program
Job Type: Full-time
Pay: $83,200.00 per year
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Paid time off
- Vision insurance
Medical specialties:
- Primary Care
Physical setting:
- Outpatient
Standard shift:
- Day shift
Weekly schedule:
- 5x8
- Monday to Friday
Experience:
- Care Coordination: 1 year (Preferred)
Ability to Relocate:
- Somerset, NJ 08873: Relocate before starting work (Required)
Work Location: In person