Partnership Health is hiring a RN Care Coordinator in Hamilton, 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
