RN, Community-Based Care Navigator & Population Health

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 through care coordination, coaching, and education across the continuum. The role focuses on improving quality, outcomes, and cost-efficiency while engaging patients and families in their care plans.

The ideal candidate has 3–5 years of hospital or ambulatory care experience, NJ RN license, and familiarity with EMR systems.

Qualifications

• Minimum of three to five years of hospital-based and/or ambulatory care experience.
• Experience with 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.
• Experience with relevant systems (e.g., electronic medical records, disease registries, Word, Excel)

Responsibilities

• Coordinate care across the healthcare continuum to manage and improve quality and cost of patient care.
• Facilitate plan of care through all care settings.
• Assess health status of populations using data from sources like EHRs and claims.
• Navigate high-risk patients and serve as main contact for providers across care settings.
• Identify high-risk patients, assess needs, and develop care plans with PCP involvement.
• Promote education, advocacy, and patient engagement to support self-management and shared decision making.
• Apply health literacy and effective communication with clients and health professionals.

Skills

PQRS/HEDIS understanding

Population health management

EMR familiarity

Education

RN license (NJ)

Tools

Electronic Medical Records (EMR)

Word

Excel

Job description

Hackensack Meridian Health is seeking an RN for Community Based Care Management to support physician practices and complex patients through care coordination, coaching, and education across the continuum. The role focuses on improving quality, outcomes, and cost-efficiency while engaging patients and families in their care plans.

The ideal candidate has 3–5 years of hospital or ambulatory care experience, NJ RN license, and familiarity with EMR systems.