rn care coordinator - Flemington, NJ , USA, United States - Hunterdon Health

    Hunterdon Health
    Hunterdon Health Flemington, NJ , USA, United States

    1 month ago

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    Description
    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.