What is your mission? 

You will provide the best service to our partner brands by performing these tasks:

• Collaborates with providers and practice staff in identifying appropriate patients for care management, utilizing established Care Management criteria.
• Performs initial and periodic holistic assessments for care-managed population. This includes physical and psychological assessments as appropriate. The assessment includes a systematic and pertinent collection of data about the health status of the patient. Prioritize patients according to intensity, need and required follow up.
• Formulates and implements a care management plan that addresses the patients identified needs by assessing the patient/family needs, issues, resources and care goals; determining the choices available to individual patients; educating the patient/family on the choices available.
• Establishes a care management plan that is mutually agreed upon by the health care team and the patient/family. Plans will contain specific mutual self-management goals, objectives, and interventions with the patients are action oriented.
• Evaluates the effectiveness of the plan in meeting established care goals; revises the plan as needed to reflect changing needs, issues and goals. If certified in Advanced Practice with prescriptive authority, may make medication adjustments as needed in collaboration with Primary Care Provider. Monitors and evaluates the progress of the patient.
• Collaborates with the healthcare team to revise the care management plan when changes occur. Initiates care conferences to discuss multidisciplinary team responsibilities, patient progress, new problems, etc.
• Identifies and effectively utilizes community resources to meet the needs of patients/families. Facilitates patient access to community resources as appropriate or refers to LSW.
• Promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence. Interacts professionally with patient/family and involves patient/family in the formation of plan of care.
• Performs follow up calls for patients recently discharged from acute hospitalizations and who are considered high risk for readmission.
• Maintains EMR databases on care managed population. Maintains accurate and timely documentation in the EMR 
• Reviews utilization and quality reports routinely and scans for gaps in care to identify patients needing the additional support of care management.
• Performs all duties and responsibilities in accordance with the Nurse Practice Act and in accordance with basic principles and guidelines of professional nursing.
• Performs medication reconciliation for all care transitions. 
• Participates in community preventative health activities i.e. school-based flu clinics.
• Participates in regular team meetings and peer review activities. Participates in quality and organizational committees. 
• Participates in the orientation of new personnel. Precepts and mentors' peers. Promotes collaborative teamwork.
• Abides by the organization's compliance program and requirements.
• Provides coverage across the organization as needed. 
• Works collaboratively with leadership team to improve and enhance care delivery through the evaluation, development and enhancement of policy and procedures.

Who are we looking for?

• Minimum of 3 year of professional level medical experience; experience in care coordination preferred.
• Must be a USRN (New Jersey)
• Experience working with an electronic medical records required.
• Excellent written and oral communication skills.
• Ability to work collaboratively with people of diverse cultures and lifestyles. 
• Ability to communicate effectively with providers and medical staff. 
• Excellent organizational skills and ability to handle multiple priorities while remaining calm and professional.
• Ability to be self-motivating and work independently.
• Computer skills proficient to expert.
• Problem solving skills.