Registered Nurse, Community Based Care Management

Registered Nurse, Community Based Care Management

HMH HOSPITALS CORPORATION, Edison, New Jersey

• Requisition #:
• Shift: Day
• Status:
  Full Time with Benefits

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.

• Provides educational and advocacy support, including complete needs assessment and comprehensive teaching programs to promote patient engagement, self‑management, and shared decision making.
• Builds relationships with patients and caregivers, translating care choices and treatment plans into clear, actionable steps.
• Disseminates educational materials and decision support tools to physicians, staff, and community members.
• Assesses and coordinates services and referrals as needed.
• Engages with partners to advocate with the community to create and implement strategies that improve the health of populations.
• Identifies community assets and resources to improve individual and population health, and participates in community education and outreach programs.
• Applies communication and health literacy strategies when working with clients and health professionals.
• Uses social media, community resources, and social marketing techniques appropriately to disseminate health information.
• Facilitates plan of care across all settings.
• Assesses health status of populations using available data such as public‑health surveillance, vital statistics, registries, surveys, electronic health records, and claims data.
• Evaluates socioeconomic, environmental, and cultural determinants of health on individual and population health outcomes.
• Navigates high‑risk patients across the continuum and serves as the main point of contact for providers.
• Identifies high‑risk patients, assesses clinical and psychosocial needs, and makes referrals to ancillary providers (disease management, pharmacy, social work, palliative care, community organizations, non‑clinical services).
• Develops coordinated care plans with primary care providers and activates patients.
• Applies primary and secondary prevention strategies that improve individual and population health.
• Facilitates prevention activities and health/wellness promotion initiatives.
• Utilizes support staff for monitoring and evaluation.
• Maintains accurate, up‑to‑date documentation in the established management record system.
• Coordinates community linkages and referrals for transportation, durable medical equipment, home health, mental health services, housing resources, dialysis, pharmaceutical authorization, palliative and hospice care.
• Promotes efficient use of resources and contributes to clinical cost‑efficiency through utilization and cost management.
• Complies with recognized standards, clinical guidelines, and quality improvement practices, and supports collection and analysis of outcome data.
• Participates in population‑health improvement strategies such as systems advocacy, program development, or community‑based interventions.
• Performs other duties and/or projects as assigned.
• Adheres to HMH organizational competencies and standards of behavior.

Education, Knowledge,

Skills and Abilities

Required

• Graduate of an accredited nursing program.
• Minimum of three‑to‑five years of hospital‑based and/or ambulatory care experience.
• Experience with PQRS, HEDIS, Meaningful Use, Patient‑Centered Medical Home, and other quality metrics and tracking.
• Knowledge of population health management and clinical integration principles and processes.
• Good working knowledge of benefit plans, including HMO, Medicare, Medicaid, employee, commercial, and Medicare Advantage.
• Experience with electronic medical records, disease registries, Microsoft Word, and Excel.

Education, Knowledge,

Skills And Abilities

Preferred

• Baccalaureate Degree.
• Primary‑care…