Registered Nurse, Community Based Care Management

Description

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.

As a part of the Care Management Team the nurse (RN) will provide direct support to physician practices and identified complex patients with targeted conditions who require care management, coaching, education, supervision, and/or support. The nurse will coordinate care, resources & services across the healthcare continuum to manage & improve the quality, effectiveness and cost of patient care. Facilitate ongoing patient communications, review gaps in care and relevant outcome measures.

A day in the life of a nurse (RN) at Hackensack Meridian Health includes:

• Effective provides/facilitates the following education & advocacy support:
• Education:
  
  Complete needs assessment, formulate and carry out a comprehensive teaching program
  -Promotes patient engagement, self-management, and shared decision making
  -Establishes relationship with patients and caregiver, if any
  -Translate care choices and treatment plans
• Physician, Staff and Community Education
  -Disseminate educational materials and decision support tools
• Advocacy Support
  -Effective assesses and coordinates services and referrals as needed
• Customer Service/Guest Relations Management
  -Engages with partners to collaborate and advocate with the community to create and implement strategies that improve the health of populations
  -Identify community assets and resources to improve the health of individuals and populations
  -Participates in community education and outreach programs
• Applies communication strategies to effective work with clients, health professionals and other sectors
• Applies health literacy when working with clients
• Uses social media, community resources and social marketing techniques appropriately to disseminate health information
• Facilitate plan of care through all settings of care
• Assess the health status of populations using available date (e.g., public health surveillance data, vital statistics, registries, surveys, electronic health records and health plan claims data)
• Assess the role of socioeconomic, environmental, cultural, and other population-level determinants of health on the health status and health care of individuals and populations served
• Navigates high-risk patients across the continuum; serves as main point of contact for patients' providers across care settings; aims to better manage patients in ambulatory setting and reduce acute care and ED use
• Identify high-risk patients, assess clinical and psychosocial needs, make referrals to ancillary providers (disease management, pharmacy, social work, palliative care, community-organizations, non-clinical services), develop care plan in coordination with PCP, engage and activate patients
• Apply primary and secondary prevention strategies that improve the health of individuals and populations
• Facilitate Prevention activities/initiatives
• Facilitate Health/Wellness Promotion
• Appropriately utilizes support staff in case monitoring and evaluation
• Utilize needs assessment to maximize / improve health status
• Makes adjustments in care plan as needed to meet goals
• Effective utilizes existing community resources in providing care/services to meet goals
• Maintains accurate, up-to-date documentation in the established management record system
• Demonstrates knowledge of and appropriately establishes Community Linkages / Referral to Community Partners / Community Resource Coordination - Transportation and Travel Arrangements, DME, Home Health/Home Infusion, Mental Health Service Coordination, Housing Resources, Dialysis Coordination and Arrangements, Pharmaceutical Authorization/Management, Pallative/End-of-Life Care, Hospice
• Promotes the most effective and efficient use of…