Job description

Position Summary: The Embedded Medical Home Care Coordinator will work on a multidisciplinary healthcare team in a primary care setting. Working alongside the physicians and office staff, they will focus on identifying the needs of complex patients, coaching and coordination of care for designated high-risk patients and communication of discharge plans to facilitate seamless, safe and effective transitions of care. They will provide a collaborative process of care coordination through the following: assessment, planning, facilitation and advocacy for healthcare options and services to meet the health care needs of patients. They will utilize resources to promote quality, cost effective outcomes as the patient transitions through the healthcare continuum.

Primary Position Responsibilities:

• Develop constructive relationships with local hospitals’ admission offices, case managers, discharge planners, and emergency department (ED) contacts.
• Work to develop systems, processes and initiatives to engage these entities in relevant case management activities with each patient to ensure that all necessary post-discharge needs are met.
• Practice Transformation: Participates in patient centered team meetings in the primary care practice and assists the practice in developing a process for managing its patient population.
• Monitor to ensure care is coordinated with home care agencies, specialists, or other resources as follows:
• Ensure follow-up primary care visits are obtained within 48 to 72 hours of discharge from a hospital or facility.
• Track follow-up visits with appropriate specialists for complex patients;
• Communicate with and coach patients about discharge instructions, including medication access, adherence and side effects.
• Facilitate and confirm timely communication between physicians and home care professionals.
• Monitor that appropriate home care, hospice care, and other ancillary services (durable medical equipment, infusion services, etc.) are in place.
• Provides ongoing individualized assessment, planning and care coordination for assigned patients during the hospital stay and documents activities in all appropriate areas of the patient's electronic medical record. Engages patient/family/caregiver in the care coordination process and discharge plan. Updates changes to plan as condition changes and communicates changes to the healthcare team.
• Utilizes required software technologies via the EMR to effectively communicate with both the Internal and External interdisciplinary healthcare teams.
• Effectively communicates the care coordination plan to patients/ families/caregivers, interdisciplinary team members, and collaborates with outpatient care coordinators to ensure a seamless transition of care, in a timely manner.
• Engages patients/families/caregivers in discharge planning process and assures a safe and effective discharge plan and transition of care while promoting self-management of chronic disease conditions.
• Supports organizational objectives of Service Excellence, Critical Success Factors and High Reliability Organization standards.

Work Contact: Hunterdon Healthcare employees, department co-workers, nurses, physicians and providers, patients/families/caregivers, all care coordinators, acute care organizations, insurance reviewers, visitors, vendors, and community agencies and sub acute facilities.

Qualifications:

Minimum Education

Required: BSN or RN with strong applicable experience including home health and/or acute care setting and/ or holds a certification in the field such as Certified Case Manager (CCM).

Minimum Years of Experience

Preferred: Five years of acute, hospital based, direct patient care experience and care coordination or Case Management experience.

License, Registry or Certification

Required: Current NJ RN licensure

Preferred: Certification in specialty (Case Management, Care Coordination)

Knowledge, Skills and/or Abilities

Required: Strong verbal, written, organizational and interpersonal communication skills.

Ability to develop and maintain collaborative relationships with the interdisciplinary team.

Comprehensive assessment and discharge planning.

Demonstrate knowledge-base in patient care evaluation and assessment, patient/family/caregiver engagement, insurance/benefits for services, community resources and research and evaluation techniques for quality improvement.

Ability to learn software applications in the EMR and new technologies.

https://pm.healthcaresource.com/cs/hhcs#/job/20531

Job Type: Full-time

Pay: $67,000.00 - $73,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Physical setting:

• Outpatient

Standard shift:

• Day shift

Weekly schedule:

• Monday to Friday

COVID-19 considerations:
New Jersey Executive Order No. 283 requires covered workers at health care facilities and high-risk congregate settings to be up to date with their COVID-19 vaccinations

Experience:

• Nursing: 3 years (Required)

License/Certification:

• RN License (Required)

Work Location: In person

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