Complex Care Coordinator (RN), Full Time (8a-4p), Morristown, NJ

Atlantic Health System•Morristown, NJ

10d

About The Position

The Complex Care Coordinator provides care coordination for high-risk and chronically ill patients in collaboration with a multidisciplinary team. The role promotes adherence to individualized care plans; communicates patient findings to primary care providers, care coordination teams, healthcare providers, and identified care partners across care settings; and applies payer clinical guidelines as applicable. The coordinator uses evidence-based risk-stratification tools to identify patients at risk of disease-related complications and deliver patient-centered interventions. When a condition exacerbates, the coordinator works with the full care team, including the patient and care partner, to support a safe return to optimal health and function in an appropriate setting. The coordinator identifies opportunities for health promotion and disease prevention, assesses social and behavioral health needs that affect patient goals, and refers patients to social work and community support services as appropriate. The role assesses self-care needs, identifies additional support requirements, educates patients and care partners about disease prevention and management, and coordinates with patients’ primary providers. It also includes maintaining confidentiality, using payer reports to identify patients for outreach, attending relevant payer webinars, supporting staff orientation and training, participating in provider outreach and education, and providing community education. The coordinator pursues ongoing professional development, maintains proficiency and regulatory compliance, and collaborates with ACO leadership on additional tasks as requested.

Requirements

Graduate of an accredited nursing program.
Bachelor of Science in Nursing (BSN) required.
Current New Jersey Registered Professional Nursing license required.
Minimum five years of clinical experience as a Registered Professional Nurse.
Strong clinical, interpersonal, analytical, prioritization, problem-solving, and organizational skills.
Ability to work with minimum direct supervision.
Ability to navigate electronic health records and databases and document clinical information electronically.
Clear and accurate verbal, telephonic, and written communication skills.

Nice To Haves

Current Pennsylvania and New York nursing licenses are a plus.
Community health experience and knowledge of community healthcare resources preferred.
Certified Case Manager (CCM) certification preferred.

Responsibilities

Coordinate patient care in collaboration with a multidisciplinary team.
Promote patient adherence to individualized plans of care.
Communicate patient findings clearly and promptly to primary care providers, care coordination teams, healthcare providers, and identified care partners across healthcare settings.
Apply payer clinical guidelines as applicable.
Use evidence-based risk-stratification tools to identify chronically ill patients at risk for disease-related complications and provide patient-centered interventions.
Collaborate with the care team, patient, and care partner to respond early to exacerbations and support a safe return to optimal health and function.
Identify opportunities for health promotion and disease prevention.
Identify social and behavioral health needs affecting patient goals and refer to social work or community support services as appropriate.
Collaborate with the multidisciplinary team to develop strategies addressing population needs.
Assess high-risk patients’ self-care needs and identify additional support requirements.
Educate patients and care partners about preventing, recognizing, and treating exacerbations and managing chronic conditions and comorbidities.
Coordinate care with patients’ primary providers and conduct provider outreach and education as applicable and under provider direction.
Maintain patient confidentiality in all Care Coordination Program activities.
Attend payer webinars as applicable and use payer reports to identify patients for outreach.
Assist with orientation and training of new staff as requested.
Participate in provider outreach and education and provide community educational programs as a community resource.
Pursue continuing education and professional development; complete ongoing proficiency and regulatory compliance requirements.
Collaborate with ACO leadership on additional tasks as requested.

Benefits

Medical, dental, vision, and prescription coverage for eligible team members working 22.5 hours per week or above.
Life and AD&D insurance.
Short-term and long-term disability coverage, with options to supplement.
403(b) retirement plan with employer match and additional non-elective contribution.
PTO and paid sick leave.
Tuition assistance, advancement, and academic advising.
Parental, adoption, and surrogacy leave.
Backup and on-site childcare.
Well-being rewards.
Employee Assistance Program (EAP).
Fertility benefits and Healthy Pregnancy Program.
Flexible spending and commuter accounts.
Pet, home and auto, identity theft, and legal insurance.