RN CARE COORDINATOR

3 weeks ago


Flemington NJ USA, United States Hunterdon Health Full time
RN Care Coordinator

This innovative position places the registered nurse (RN) in a Care Coordinator role partnering with primary care providers. The majority of our primary care practices are certified Patient-Centered Medical Homes (PCMH). The Medical Home Care Coordinator is a vital part of the multidisciplinary healthcare team which strives to coordinate care and optimize outcomes for patients and our healthcare system.

Care Transition Coaching and Coordination
• Reduce unnecessary hospitalizations and re-hospitalizations by working with patients who were discharged from various healthcare facilities. Work with the primary care team to ensure follow-up visits are scheduled within 48 hours of facility discharge.
• Use Motivational Interviewing and coaching strategies to help patients identify and meet their healthcare goals.
• Develop individualized care plans to help patients track and meet their goals.
• Provide care coordination strategies via telephonic support and/or face-to-face to engage and educate patients.
• Develop and promote constructive relationships with inpatient, outpatient and community personnel to meet patient needs and goals.
• Guide process and performance improvement initiatives in the primary care setting to meet strategic goals.
• Engage with home care agencies, specialists, and any other integral providers or resources in case management activities.

Population Management
• Prioritize high risk patient needs with physicians, office staff, and the health care team.
• Leverage clinical informatics to identify high risk, high need, and potentially high cost patients of the medical home to manage their care.
• Utilize electronic medical record (EMR) and chronic disease registry reporting to prioritize patient outreach.
• Coordinate with Case Management and Disease Management staff when applicable

Qualifications

Education/Experience:
• RN licensure required. BSN preferred.
• Certified Case Management (CCM) preferred
• Five to eight years of direct patient care experience required
• Must have experience with Microsoft Office (Word, Excel, PowerPoint).
• Must possess the ability to quickly learn new IT systems and software.
• Must be able to adjust and prioritize tasks in a dynamic environment.
• Experience with an EMR strongly preferred
• Experience analyzing, sorting and drawing conclusions from data strongly preferred.
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