RN, Community Based Care Management

About the role

As a part of the Care Management Team the nurse (RN) 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.

Responsibilities

• Complete needs assessment, formulate and carry out a comprehensive teaching program
• Promote patient engagement, self-management, and shared decision making
• Establish 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
• Assess and coordinate services and referrals as needed
• Engage 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
• Participate in community education and outreach programs
• Apply communication strategies to effective work with clients, health professionals and other sectors
• Apply health literacy when working with clients
• Use 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 data (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
• Navigate high-risk patients across the continuum; serve as main point of contact for patients' providers across care settings; aim 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 utilize support staff in case monitoring and evaluation
• Utilize needs assessment to maximize / improve health status
• Make adjustments in care plan as needed to meet goals
• Effectively utilize existing community resources in providing care/services to meet goals
• Maintain accurate, up-to-date documentation in the established management record system
• Demonstrate knowledge of and appropriately establish 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, Palliative/End-of-Life Care, Hospice
• Promote the most effective and efficient use of resources
• Health Care Resource Management/Clinical Cost Efficiency - Financial Assistance/Referrals - Utilization/Cost Management
• Comply 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
• Support 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
• Adhere to HMH Organizational competencies and standards of behavior

Qualifications

• 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

Preferred qualifications

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