Integrated Care Navigator for Complex Chronic Illness

Atlantic Health; Morristown (NJ); On-site; USD 60,000 - 90,000; Full time

Job summary

Atlantic Health is seeking a Care Coordination professional to assist patients referred for access to healthcare resources due to complex chronic illness and psychiatric diagnoses. You will coordinate care, educate patients, build trust with medical teams, and improve communication and continuity of care.

The role emphasizes education, preventive care, and disease management through collaboration with a multidisciplinary team, and ongoing professional development.

Responsibilities

• Performs care coordination for high-risk patients to ensure continuity of care and quality delivery across the care continuum.
• Utilizes established clinical pathways to facilitate comprehensive chronic disease 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.
• Communicates patient findings to primary care provider, Care Coordination Team, and other providers.
• Uses risk-stratification tools to identify patients at risk and deliver evidence-based interventions.
• Intervenes early during exacerbations through multidisciplinary collaboration.
• Identifies opportunities for health promotion and disease prevention.
• Assesses/refers patients to community support services as needed.
• Collaborates with team to develop innovative population strategies.
• Assesses self-care needs and educates patients and care-partners on prevention and self-management.
• Participates in research, performance improvement, and quality initiatives.
• Maintains ongoing professional development and regulatory compliance.
• Assists in orientation and training of new staff and participates in provider outreach and education.
• Collaborates with AHS leadership on additional tasks as requested.

Skills

Care coordination

Patient education

Communication

Team collaboration

Job description

Atlantic Health is seeking a Care Coordination professional to assist patients referred for access to healthcare resources due to complex chronic illness and psychiatric diagnoses. You will coordinate care, educate patients, build trust with medical teams, and improve communication and continuity of care.

The role emphasizes education, preventive care, and disease management through collaboration with a multidisciplinary team, and ongoing professional development.