Atlantic Health System is seeking a Complex Care Coordinator to work on our Care Coordination department located at 465 South Street, Morristown, NJ. This incredible opportunity is full-time.
Performs care coordination for high-risk patients to ensure continuity of care and quality healthcare delivery across the care continuum. Spanning the ED/OBS, inpatient, post- acute, and home settings. Utilizes established clinical pathways to facilitate comprehensive and consistent chronic disease specific condition education.
Maintains patient confidentiality with all activities in the Care Coordination Program.
Provides care coordination by collaborating with a multidisciplinary team. Promotes patient adherence to individualized plan of care. Collaborates and communicates patient findings to primary care provider, Care Coordination Team, and healthcare providers, and identified care-partner(s) as appropriate across various health care settings via timely, accurate, and clear communication modalities.
Utilizes evidence-based risk-stratification tools to proactively assess chronically-ill population, identify patients at risk for disease-related sequelae and deliver patient-centered evidence-based interventions to prevent future progression or exacerbation of illness. During exacerbation, intervenes at the earliest opportunity through multidisciplinary collaboration with all members of the care team, including patient and identified care-partner to return the patient safely to optimal level of health/function in an optimal setting. Identifies opportunities for health promotion and disease prevention. Identifies Social/Behavioral Health needs which impacts patient's outcomes and appropriately refers to Social Work team member. Assess/Refer patients to available community support services as deemed necessary. Collaborates with multidisciplinary team to develop innovative strategies addressing the needs of the population.
Assesses the self-care needs of the high-risk patient and identifies need for additional support. Provides patient/care-partner(s) education regarding prevention/recognition/treatment of disease exacerbation and promotes self-management of chronic condition and comorbidities.
Participates in evidence-based research, performance improvement, and quality initiatives as appropriate.
Demonstrates professional conduct in accordance with PRIDE core values (Professionalism, Respect, Involvement, Dignity and Excellence).
Assumes responsibility and accountability for professional development and pursues ongoing continuing education in order to deliver patient-centered care. Demonstrates successful completion of ongoing proficiency and compliance with regulatory requirements.
Assists in orientation and training of new staff as requested. Participates in provider outreach and education. Serves as a community resource, providing educational programs for the community.
Collaborates with AHS leadership on additional tasks as requested.
Ability to work with minimum direct supervision
Ability to navigate EHR and data bases with demonstrated ability for electronic clinical documentation
Clear and accurate verbal, telephonic, and written communication skills
Graduate of an accredited Nursing Program; BSN required
Current NJ Registered Professional Nursing license required
Current PA and NY Nursing license a plus
CCM certification preferred
5+ years of clinical experience as a Registered Professional Nurse
Community health experience and knowledge of community healthcare resources preferred
Strong clinical, interpersonal, analytical, priority setting, problem solving and organizational skills
Willingness to travel and flexibility in work schedule is a must
Atlantic Health System aims to deliver the highest quality, safety and care combined with the best experience for our patients and their families. We are confident that you will find success within Atlantic Health System, which has been named for the 14th year in a row to Fortune's 'Top 100 Best U.S. Companies to Work For' list. We believe you will find that our culture of collaboration and care exemplifies the value we place on our patients, their families, and our employees.
Atlantic Health System, Inc. is an equal employment opportunity employer and federal contractor or subcontractor and therefore abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, citizenship status, disability, age, genetics, or veteran status.