Complex Care Coordinator; RN Corporate Headquarters, Atlantic Health

Job Description

Responsible for assisting patients referred to AHS for assistance in accessing and utilizing health care resources due to their complex chronic illness and co-occurring psychiatric diagnoses. Improves health outcomes through coordinating care, educating patients, building trust between patients and medical practitioners, and enhancing communication and the continuity of care. Teaches, counsels, and monitors patients on health issues relevant to their care.

Consults with other health care team members to coordinate the services of patient education, preventive care, and disease management.

• Perform care coordination for high‑risk patients to ensure continuity of care and quality healthcare delivery across the care continuum.
• Utilize established clinical pathways to facilitate comprehensive and consistent chronic disease‑specific condition education.
• Maintain patient confidentiality with all activities in the Care Coordination Program.
• Provide care coordination by collaborating with a multidisciplinary team.
• Promote patient adherence to individualized plan of care.
• Collaborate and communicate patient findings to primary care provider, Care Coordination Team, and other healthcare providers, and identified care partners as appropriate across various health care settings via timely, accurate, and clear communication modalities.
• Utilize evidence‑based risk‑stratification tools to proactively assess a 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, intervene 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.
• Identify opportunities for health promotion and disease prevention, and identify social/behavioral health needs which impact patient outcomes and appropriately refer to social work team members.
• Assess and refer patients to available community support services as deemed necessary.
• Collaborate with multidisciplinary team to develop innovative strategies addressing the needs of the population.
• Assess the self‑care needs of the high‑risk patient and identify need for additional support. Provide patient/care partner education regarding prevention/recognition/treatment of disease exacerbation and promote self‑management of chronic condition and comorbidities.
• Participate in evidence‑based research, performance improvement, and quality initiatives as appropriate.
• Assume responsibility and accountability for professional development and pursue ongoing continuing education to deliver patient‑centered care. Demonstrate successful completion of ongoing proficiency and compliance with regulatory requirements.
• Assist in orientation and training of new staff as requested. Participate in provider outreach and education. Serve as a community resource, providing educational programs for the community.
• Collaborate with AHS leadership on additional tasks as requested.

Required:

• Graduate of an accredited nursing program; BSN required.
• Current NJ Registered Professional Nursing license required.
• Current PA and NY Nursing license a plus.
• Minimum 5 years of clinical experience as a Registered Professional Nurse.

Preferred:

• Community health experience and knowledge of community healthcare resources preferred.
• CCM certification preferred.

Atlantic Health offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well‑being of all team members. Offerings vary based on role level (Team Member, Director, Executive). Below is a general summary, with role‑specific enhancements highlighted:

• Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full‑time and part‑time team members)
• Life & AD&D Insurance.
• Short‑Term and Long‑Term Disability (with options to supplement)
• 403(b) Retirement Plan:
  Employer match, additional non‑elective…