RN Care Coordinator

Hunterdon Healthcare Partners; Flemington (NJ); On-site; USD 70,000 - 75,000; Full time

Job summary

Hunterdon Healthcare Partners is seeking an RN Care Coordinator to support high-risk outpatient populations, coordinating care across primary and specialty services to ensure safe transitions of care.

The role emphasizes engagement with hospitals, subacute facilities, and home health teams, using EMR and pursuing CMS-compliant Transition Care Management visits. Strong communication and collaboration are essential.

Qualifications

• BSN or RN with appropriate experience and CCM certification preferred.
• Minimum three years of acute, hospital-based direct patient care.
• Preferred five years of acute care with care coordination experience.
• Current NJ RN licensure.
• Strong verbal and written communication; ability to collaborate.

Responsibilities

• Provide outreach to identified patients, addressing social determinants of health, barriers to care, education on disease state and medications, coordinating care needs with primary care, specialty care and ancillary services.
• Develop constructive relationships with hospitals' admission offices, case managers, discharge planners, and ED contacts.
• Develop systems and processes to engage entities in care management and ensure post-discharge needs are met.
• Monitor coordination with home care agencies, specialists, or other resources.
• Ensure Transition Care Management visits are completed within CMS guidelines and facilitate follow-up visits with appropriate specialists.
• Educate patients and caregivers about new diagnoses, medications, and discharge instructions.
• Monitor that home care, hospice, and other ancillary services are in place.
• Utilize EMR to communicate with interdisciplinary teams.
• Assist with review of internal/payor reports to target populations and close gaps in care.
• Facilitate transportation services per policy.
• Attend scheduled or ad-hoc meetings or committees as requested.

Skills

Communication skills

Care coordination

Team collaboration

RN licensure

Education

RN with BSN

Tools

EMR

Job description

Position Summary: The RN Care Coordinator will work as part of a multidisciplinary healthcare team supporting patients in the outpatient setting. In collaboration with the patient’s healthcare team, the RN Care Coordinator will focus on the coordination of care for targeted high risk patient populations to facilitate seamless, safe and effective transitions of care. They will utilize appropriate resources to promote quality, cost effective outcomes, as the patient transitions through the healthcare continuum.

Primary Position Responsibilities:

• Provide outreach to identified patients, providing assistance to address social determinants of health, barriers to care, education on disease state and medications, coordinating care needs with primary care, specialty care and ancillary services.
• Develop constructive relationships with local hospitals’ and subacute care facilities’ admission offices, case managers, discharge planners, and emergency department (ED) contacts.
• Work to develop systems, processes and initiatives to engage these entities in relevant care management activities with each patient to ensure that necessary post-discharge and on-going medical needs are met.
• Monitor to ensure care is coordinated with home care agencies, specialists, or

other resources as follows:

• Ensure Transition Care Management (TCM) visits (with Specialist or Primary Care Provider) are completed within CMS guidelines. Facilitate follow-up visits with appropriate specialists and review recommendations with complex patients;
• Communicate with and educate patients (and/or their caregivers as appropriate) about new diagnoses, medications, and discharge instructions.
• Monitor that appropriate home care, hospice care, and other ancillary services (durable medical equipment, infusion services, etc.) are in place.

• Utilize required software technologies, including but not limited to the EMR to effectively communicate with interdisciplinary healthcare teams.
• Assist with review and analysis of internal and payor reports to target specific populations and close gaps in care and optimize outcomes.
• Facilitate transportation services for specified individuals based on policies and protocols.
• Work collaboratively with all members of the team, being available to attend any scheduled or ad-hoc meetings or participate in committees or work groups as requested.

Work Contact: Hunterdon Health Case Management/Social Work Team, Hunterdon Home Health/Hospice Team, HHP Care Coordination Team, HMG Care Coordinators, Independent Practice Care Coordinators, HHP Primary Care and Speciality Care Practices, Insurance Plans Case Management Teams, Sub Acute Facilities, others as determined based on job functions.

Qualifications:

Required: BSN or RN with strong applicable experience including home health and/or acute care setting and/ or holds a certification in the field such as Certified Case Manager (CCM).

Minimum Years of Experience

Required: Three years of acute, hospital based, direct patient care experience. Applicants with 3 years of home health or subacute nursing may also be considered.

Preferred: Five years of acute, hospital based, direct patient care experience and care coordination or Case Management experience.

License, Registry or Certification

Required: Current NJ RN licensure

Preferred: Certification in specialty (Case Management, Care Coordination)

Knowledge, Skills and/or Abilities

Required: Strong verbal, written, organizational and interpersonal communication skills.

Ability to develop and maintain collaborative relationships with the interdisciplinary team and co-workers. Comprehensive assessment and discharge planning. Demonstrate knowledge-base in patient care evaluation and assessment, patient/family/caregiver engagement, insurance/benefits for services, community resources and,research and evaluation techniques for quality improvement. Ability to learn current software applications and new technologies.

HIRING SALARY=$70,000 - $75,000/yr

The hiring range listed is the potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement. When determining an applicant’s hourly rate and/or base salary, several factors may be considered as applicable (e.g., years of relevant experience, education, internal equity, and specialty).