RN, Community Based Care Management

Hackensack Meridian Health; Edison (NJ); On-site; USD 83,000 - 101,000; Full time

Job summary

Hackensack Meridian Health is seeking an RN for Community Based Care Management to support physician practices and complex patients with targeted conditions. The role focuses on coordinating care across the continuum, providing education, and improving quality, effectiveness, and cost of patient care.

The nurse will facilitate patient communications, review care gaps, and engage with caregivers and providers to implement care plans in ambulatory settings.

Qualifications

• RN license and nursing degree.
• 3–5 years hospital or ambulatory care experience.
• Experience with PQRS, HEDIS and Meaningful Use metrics.
• Knowledge of population health management and clinical integration.

Responsibilities

• Provide education and advocacy to patients and families.
• Coordinate care across the healthcare continuum to improve outcomes.
• Review gaps in care and relevant outcome measures with physicians and care teams.
• Navigate high‑risk patients across care settings and activate patients.

Skills

PQRS knowledge

HEDIS knowledge

Meaningful Use

Population health management

Electronic health records

Care coordination

Education

Graduate of accredited Nursing Program

RN License (NJ)

Tools

EMR systems

Job description

Description

Our team members are the heart of what makes us better.

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.

Responsibilties

A day in the life of a RN, Community Based Care Management 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 16. 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 resources
• Health Care Resource Management/Clinical Cost Efficiency -Financial Assistance/Referrals -Utilization/Cost Management
• Compliant with Recognized Standards or Guidelines for practice, Service Specific Policies and Regulatory Agencies / Standards Governing Services/operations -Clinical Guidelines/Pathways/Evidenced Base Practice -Quality Improvement Practice Standards -Supports collection and analysis of outcomes data (e.g., clinical, financial, variance, patient satisfaction) -Use data to evaluate quality and cost measures
• Participate in population health improvement strategies (e.g., systems and policy advocacy, program or policy development, or other community-based interventions).
• Other duties and/or projects as assigned.
• Adheres to HMH Organizational competencies and standards of behavior.

Qualifications

Education, Knowledge, Skills and Abilities Required:

• Graduate of accredited Nursing Program .
• Minimum of three to five years of hospital based and/or ambulatory care experience.
• Experience with and knowledge about PQRS, HEDIS, Meaningful Use, Patient-Centered Medical Home, and other quality metrics and tracking.
• Knowledgeable about population health management and clinical integration principles and processes.
• Good working knowledge of benefit plans: HMO, Medicare, Medicaid, Employee, Commercial, Medicare Advantage, etc.
• Experience with relevant systems (e.g., electronic medical records, disease registries, Word, Excel)

Education, Knowledge, Skills And Abilities Preferred

• Baccalaureate Degree.
• Primary care experience preferred, but other specialties acceptable.

Licenses And Certifications Required

• NJ State Professional Registered Nurse License.

HMH is committed to pay equity and transparency for our team members. The posted rate of pay in this job posting is a reasonable good faith estimate of the minimum base pay for this role at the time of posting in accordance with the New Jersey Pay Transparency Act and does not reflect the full value of our market-competitive total rewards package.

Job Duties

The starting rate of pay is provided for informational purposes only and is not a guarantee of a specific offer. Posted hourly rates may be stated as an annual salary in the offer and posted annual salaries may be stated as an hourly rate in the offer, depending on the level and nature of the job duties and credentials of the candidate. The base compensation determined at the time of the offer may be different than the posted rate of pay based on a number of non-discriminatory factors, including but not limited to:

• Labor Market Data: Compensation is benchmarked against market data to ensure competitiveness.
• Experience: Years of relevant work experience.
• Education and Certifications: Level of education attained, including specialized certifications, credentials, completed apprenticeship programs or advanced training.
• Skills: Demonstrated proficiency in relevant skills and competencies.
• Geographic Location: Cost of living and market rates for the specific location.
• Internal Equity: Compensation is determined in a manner consistent with compensation ranges for similar roles within the organization.
• Budget and Grant Funding: Departmental budgets and any grant funding associated with the job position may impact the pay that can be offered.

Some jobs may also be eligible for performance-based incentives, bonuses, or commissions not reflected in the starting rate. Certain positions may also be eligible for shift differentials for work performed on evening, night, or weekend shifts. In addition to our compensation for full-time and part-time (20+ hours/week) job positions, HMH offers a comprehensive benefits package, including health, dental, vision, paid leave, tuition reimbursement, and retirement benefits.Minimum rate of $92,144.00 Annually