Complex Care Navigator RN for High-Risk Patients

Atlantic Health System; Morristown (NJ); On-site; USD 70,000 - 95,000; Full time

Job summary

Atlantic Health System is seeking a Care Coordination professional to assist patients with complex chronic illness and co-occurring psychiatric diagnoses. You will coordinate care, educate patients, and support communication between patients and the medical team to improve health outcomes.

Morristown, NJ-based role with a focus on comprehensive care delivery. In this role, you will collaborate with a multidisciplinary team, apply evidence-based pathways, protect patient confidentiality, and

Responsibilities

• Performs care coordination for high-risk patients to ensure continuity of care and quality healthcare delivery across the care continuum.
• Utilizes established clinical pathways to facilitate comprehensive and consistent chronic disease specific condition education.
• Maintains patient confidentiality with all activities in the Care Coordination Program.
• Provides care coordination by collaborating with a multidisciplinary team.
• Promotes patient adherence to individualized plan of care.
• Collaborates and communicates patient findings to primary care provider, Care Coordination Team, and healthcare providers, and identified care-partner(s) as appropriate across various health care settings via timely, accurate, and clear communication modalities.
• Utilizes evidence-based risk-stratification tools to proactively assess 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, intervenes 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.
• Identifies opportunities for health promotion and disease prevention. Identifies Social/Behavioral Health needs which impacts patient's outcomes and appropriately refers to Social Work team member.
• Assesses/Refers patients to available community support services as deemed necessary.
• Collaborates with multidisciplinary team to develop innovative strategies addressing the needs of the population.
• Assesses the self-care needs of the high-risk patient and identifies need for additional support. Provides patient/care-partner(s) education regarding prevention/recognition/treatment of disease exacerbation and promotes self-management of chronic condition and comorbidities.
• Participates in evidence-based research, performance improvement, and quality initiatives as appropriate.
• Assumes responsibility and accountability for professional development and pursues ongoing continuing education to deliver patient-centered care. Demonstrates successful completion of ongoing proficiency and compliance with regulatory requirements.
• Assists in orientation and training of new staff as requested. Participates in provider outreach and education. Serves as a community resource, providing educational programs for the community.
• Collaborates with AHS leadership on additional tasks as requested.

Job description

Atlantic Health System is seeking a Care Coordination professional to assist patients with complex chronic illness and co-occurring psychiatric diagnoses. You will coordinate care, educate patients, and support communication between patients and the medical team to improve health outcomes.

Morristown, NJ-based role with a focus on comprehensive care delivery. In this role, you will collaborate with a multidisciplinary team, apply evidence-based pathways, protect patient confidentiality, and