Responsible for assisting patients referred to AHS for assistance in accessing and utilizing health care resources due to their complex chronic illness and co-occurring psychiatric diagnoses. Improves health outcomes through coordinating care, educating patients, building trust between patients and medical practitioners, and enhancing communication and the continuity of care. Teaches, counsels and monitors patients on health issues relevant to their care.
Consults with other health care team members to coordinate the services of patient education, preventive care and disease management. Principal Accountabilities: 1. Performs care coordination for high-risk patients to ensure continuity of care and quality healthcare delivery across the care continuum. 2.
Utilizes established clinical pathways to facilitate comprehensive and consistent chronic disease specific condition education. 3. Maintains patient confidentiality with all activities in the Care Coordination Program. 4. Provides care coordination by collaborating with a multidisciplinary team. 5.
Promotes patient adherence to individualized plan of care.? 6. 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. 7. 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. 8.
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. 9. 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. 10.
Assesses/Refers patients to available community support services as deemed necessary.? 11. Collaborates with multidisciplinary team to develop innovative strategies addressing the needs of the population.? 12. 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. 13. Participates in evidence-based research, performance improvement, and quality initiatives as appropriate.? 14. 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. 15. 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. 16. Collaborates with AHS leadership on additional tasks as requested.? ? Required: 1.
Graduate of an accredited Nursing Program; BSN required 2. Current NJ Registered Professional Nursing license required. 4. Current PA and NY Nursing license a plus. 5.
Minimum 5 years of clinical experience as a Registered Professional Nurse. Preferred: 1. Community health experience and knowledge of community healthcare resources preferred 2.
CCM certification preferred.
Full-Time