- Perform a needs assessment of very high risk patients (with their input) to maximize or improve current health status and independence while preventing or slowing deterioration of existing health problems.
- Ability to perform extensive telephone assessment and triage of patients.
- Able to review office charts to identify gaps in care and coordinate services and the care team to manage these issues.
- Work within a multi-disciplinary team to develop and implement a comprehensive plan of care for very high risk Medicare ACO patients.
- Utilize clinical tools such as protocols, physician orders, and care coordination models to maximize patient care. Work within the multi-disciplinary team to create new and update existing tools.
- Identify patient and care giver learning needs, assess their ability to learn, then formulate a comprehensive teaching program individual to that patients unique health issues.
- Work collaboratively with physicians to ensure patient adherence to medical plan, including all appropriate preventative and disease-specific screenings, interventions, and treatment goals including self-management goals.
- When necessary or as directed, travel to patient locations such as hospital, skilled nursing facility, etc. to assess patient needs and status.
- Assist patients and their care givers in obtaining referrals to a specific specialist. Communicate with referring physician offices as required to optimize patient care, decrease costs and increase patient satisfaction. Track these visits for High Risk population.
- Facilitate communication of patient status and plan of care during transitional experiences such as home to hospital, hospital to post acute care facility, and back to home. The Navigator will communicate with the primary physician, patient or care giver, and any transitional care staff that are available, such as Hospitalists, Case Managers, Social Workers, etc.
- Directly involved with the development and enhancement processes of the ACO with the aim to improve the clinical experience and satisfaction of services for referred patients and/or physicians.
- Become familiar with and utilize the services and programs in the community to support and assist patients at home.
- Monitor that appropriate home care, hospice and other ancillary services are in place and are being delivered as directed by the care team.
- Monitor and facilitate compliance with required quality measures for all ACO patients.
- Collect and report data as deemed necessary and by request of Supervisor to analyze possible gaps in care, focus on quality improvement processes and to track status of patient care.
- Attend required training and collaboration sessions as scheduled.
- Flexibility in work schedule to accommodate needs of patient and care givers.
- Graduate of an accredited program in Nursing.
- Minimum of 5+ recent years in nursing.
- Highly developed interpersonal skills including motivational interviewing skills, in order to interact effectively and motivate patients to change behavior when necessary.
- Must be proficient at multi-tasking and prioritization working in a high volume environment with little supervision.
- Ability to work independently as well as in a team environment.
- Excellent analytical and deduction skills.
- Good reasoning and problem solving ability and be able to take initiative in finding solutions to difficult and/or sensitive problems.
- Must be organized and able to multi-task.
- Ability to work in stressful situations and be flexible to accommodate patient and family needs.
- Demonstrated proficiency and comfort with PC and Microsoft office skills.
- Bachelor of Science in Nursing (BSN).
- Experience in a variety of patient settings is recommended.
- NJ State Professional Registered Nurse License.
-
Hackensack Meridian Health Hackensack, United StatesOverview: · Our team members are the heart of what makes us better. · At Hackensack Meridian Health we help our patients live better, healthier lives and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, ...
-
Hackensack Meridian Health Hackensack, NJ , USA, United StatesOur team members are the heart of what makes us better. · At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitiv ...
-
Hackensack Meridian Health Hackensack, United StatesOverview · Our team members are the heart of what makes us better. · At Hackensack Meridian Health we help our patients live better, healthier lives - and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here ...
-
Rn Clinical Director Ft
1 week ago
United Surgical Partners International Inc (USPI) Hackensack, United States**_Metropolitan Surgery Center_** **has an immediate need for a RN Clinical Director · - **Monday to Friday work schedule**: · - **Off on weekends and holidays**: · - **No call required** · **Job Summary**: The Clinical Director is responsible for overseeing and developing the am ...
-
Advanced Practice Nurse
2 weeks ago
Shaker Medical Group Hackensack, United States**About Us**: · Shaker Medical Group is a proud partner with Holy Name Medical Center and is a leading healthcare organization committed to providing exceptional patient care and promoting medical excellence. Our team of dedicated professionals strives to make a positive impact o ...
-
Eyecare Advisor
2 weeks ago
Target Optical Hackensack, United States**Requisition ID**:845506 · **Store #**: Target Optical · **Position**:Full-Time · **Total Rewards**:Benefits/Incentive Information** · At Target Optical, we are on a mission to be the ally that WOW's all families shopping at Target, by offering an easy and inspiring optical expe ...
-
Social Worker-geriatric
2 weeks ago
Hackensack Meridian Health Hackensack, United StatesOverview: · Our team members are the heart of what makes us better. · At **Hackensack Meridian **_Health_** we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team member ...
-
Early Childhood Education Teacher's Assistant
2 weeks ago
Hackensack Meridian Health Hackensack, United StatesOverview: · Our team members are the heart of what makes us better. At Hackensack Meridian _Health_ we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, ...
-
Geriatric Surgery Coordinator
5 hours ago
Hackensack Meridian Health Hackensack, United StatesOverview: · Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, c ...
-
Perfumery Sample Lab Technician
2 days ago
OnScent Hackensack, United StatesOnScent is a manufacturer of fragrance and natural cosmetic solutions with world class natural, organic and sustainable materials for the fragrance, cosmetic and personal care industries. We are in search of Perfumery Sample Lab Technicians who will be working out of our Norwood, ...
-
Health Information Scanning Analyst
6 days ago
Hackensack Meridian Health Hackensack, United StatesOverview: · Our team members are the heart of what makes us better. · At **Hackensack Meridian **_Health_** we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team member ...
-
Loan Officer
5 hours ago
Homeland Lending Hackensack, United States**Why Join Us?**: · To be successful as a professional mortgage banker, organization is paramount. The company you choose to stake your reputation with must provide the most exceptional platform required to differentiate themselves _from_ the average Loan Officer. · Our Loan Offi ...
-
Farm Hand
2 days ago
REED Autism Services Hackensack, United StatesGreens Do Good is a year-round indoor vertical farm growing fresh basil, lettuce, kale and microgreens in the heart of Hackensack, NJ. Hydroponic vertical farming is an innovative method of growing plants using space saving stacked trays and energy efficient lighting and watering ...
-
Research Assistant
1 week ago
Hackensack Meridian Health Hackensack, United StatesOverview: · Our team members are the heart of what makes us better. · At **Hackensack Meridian **_Health_** we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team member ...
-
Equipment Technician, Respiratory
1 week ago
Hackensack Meridian Health Hackensack, United StatesOverview: · Our team members are the heart of what makes us better. At Hackensack Meridian _Health_ we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, ...
-
Psychosocial Assistant, Full-time
6 days ago
Hackensack Meridian Health Hackensack, United States Full timeOverview: · Our team members are the heart of what makes us better. At Hackensack Meridian _Health_ we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, ...
-
Medical Receptionist
1 week ago
Cahill Orthopedic Hackensack, United StatesBusy Orthopedic practice looking to hire a full time medical receptionist ASAP. Full time position Monday-Friday 8-5 2 days a week, 9-5 3 days a week. Orthopedic experience a must. Knowledge of icd-10 and EMR programs. Athena knowledge a plus · **Responsibilities**: · - Greet and ...
-
State Controller
1 day ago
RAPS PROFESSIONAL SERVICES PRIVATE LIMITED Hackensack, United States**Role: State Controller** · **Location: Hackensack, NJ 07601** · **Duration: Permanent Full Time** · **Shift: Day Shift** · - Primary leader to the accounting/finance team · - Reports monthly results to key stakeholders in a timely manner with appropriate analysis of key perform ...
-
Finance, Planning
1 week ago
OnScent Hackensack, United States**OnScent** is a disruptive new force in the fragrance industry founded on decades of experience. We are an international manufacturer of fragrance and natural cosmetic solutions with world class natural, organic and sustainable materials for the fragrance, cosmetic and personal ...
-
Practice Coordinator
2 weeks ago
Great Expressions Dental Centers Hackensack, United StatesWhat you'll do · As a Patient Coordinator, you will be the first point of contact for patients visiting or calling the dental office. Your primary responsibility is to provide exceptional customer service by greeting patients, scheduling appointments, managing patient records, an ...
Patient Navigator, Accountable Care Organization - Hackensack, United States - Hackensack Meridian Health
Description
Overview
Our team members are the heart of what makes us better.
At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It's also about how we support one another and how we show up for our community.
Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.
A Patient Navigator, ACO works closely with primary care physicians and various specialty physicians and services to maximize the health status of patients. This position requires a high frequency of contact with the very high risk ACO patient and their care givers for education of health promotion and self care skills as well as facilitating compliance with the required quality measures for all ACO patients. A Patient Navigator will also ensure the coordination and communication of a patient's treatment plan and general status to all care givers during all transitions of care. This position requires advanced nursing knowledge and expertise to identify and implement improvement processes and the ability to direct and implement care coordination plans both in both in-patient and out-patient settings.
Responsibilities
A day in the life of a Patient Navigator, ACO at Hackensack Meridian Health includes:
Qualifications
Education, Knowledge, Skills and Abilities Required :
Education, Knowledge, Skills and Abilities Preferred :
Licenses and Certifications Required :
If you feel that the above description speaks directly to your strengths and capabilities, then please apply today