Partnership Health is hiring a RN Care Coordinator in Somerville, 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

Work Location: In person