RN Community Based Care Management

Hackensack Meridian Health•Edison, NJ

About The Position

As a part of the Care Management Team the RN Community Based Care Management will provide direct support to physician practices and identified complex patients with targeted conditions who require care management, coaching, education, supervision, and/or support. The nurse will coordinate care, resources & services across the healthcare continuum to manage & improve the quality, effectiveness and cost of patient care. Facilitate ongoing patient communications, review gaps in care and relevant outcome measures.

Requirements

Graduate of accredited Nursing Program .
Minimum of three to five years of hospital based and/or ambulatory care experience.
Experience with and knowledge about PQRS, HEDIS, Meaningful Use, Patient-Centered Medical Home, and other quality metrics and tracking.
Knowledgeable about population health management and clinical integration principles and processes.
Good working knowledge of benefit plans: HMO, Medicare, Medicaid, Employee, Commercial, Medicare Advantage, etc.
Experience with relevant systems (e.g., electronic medical records, disease registries, Word, Excel)
NJ State Professional Registered Nurse License.

Nice To Haves

Baccalaureate Degree.
Primary care experience preferred, but other specialties acceptable.

Responsibilities

Provides/facilitates education & advocacy support: Education: Complete needs assessment, formulate and carry out a comprehensive teaching program -Promotes patient engagement, self-management, and shared decision making -Establishes relationship with patients and caregiver, if any -Translate care choices and treatment plans
Physician, Staff and Community Education -Disseminate educational materials and decision support tools
Advocacy Support -Effective assesses and coordinates services and referrals as needed
Customer Service/Guest Relations Management -Engages with partners to collaborate and advocate with the community to create and implement strategies that improve the health of populations -Identify community assets and resources to improve the health of individuals and populations -Participates in community education and outreach programs
Applies communication strategies to effective work with clients, health professionals and other sectors
Applies health literacy when working with clients
Uses social media, community resources and social marketing techniques appropriately to disseminate health information
Facilitate plan of care through all settings of care
Assess the health status of populations using available date (e.g., public health surveillance data, vital statistics, registries, surveys, electronic health records and health plan claims data)
Assess the role of socioeconomic, environmental, cultural, and other population-level determinants of health on the health status and health care of individuals and populations served
Navigates high-risk patients across the continuum; serves as main point of contact for patients' providers across care settings; aims to better manage patients in ambulatory setting and reduce acute care and ED use
Identify high-risk patients, assess clinical and psychosocial needs, make referrals to ancillary providers (disease management, pharmacy, social work, palliative care, community-organizations, non-clinical services), develop care plan in coordination with PCP, engage and activate patients
Apply primary and secondary prevention strategies that improve the health of individuals and populations
Facilitate Prevention activities/initiatives
Facilitate Health/Wellness Promotion
Appropriately utilizes support staff in case monitoring and evaluation
Utilize needs assessment to maximize / improve health status
Makes adjustments in care plan as needed to meet goals
Effective utilizes existing community resources in providing care/services to meet goals
Maintains accurate, up-to-date documentation in the established management record system
Demonstrates knowledge of and appropriately establishes Community Linkages / Referral to Community Partners / Community Resource Coordination - Transportation and Travel Arrangements, DME, Home Health/Home Infusion, Mental Health Service Coordination, Housing Resources, Dialysis Coordination and Arrangements, Pharmaceutical Authorization/Management, Pallative/End-of-Life Care, Hospice
Promotes the most effective and efficient use of resources
Health Care Resource Management/Clinical Cost Efficiency -Financial Assistance/Referrals -Utilization/Cost Management
Compliant with Recognized Standards or Guidelines for practice, Service Specific Policies and Regulatory Agencies / Standards Governing Services/operations -Clinical Guidelines/Pathways/Evidenced Base Practice -Quality Improvement Practice Standards -Supports collection and analysis of outcomes data (e.g., clinical, financial, variance, patient satisfaction) -Use data to evaluate quality and cost measures
Participate in population health improvement strategies (e.g., systems and policy advocacy, program or policy development, or other community-based interventions).
Other duties and/or projects as assigned.
Adheres to HMH Organizational competencies and standards of behavior.