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The RN, Community Based Care Management provides direct support to physician practices and identifies complex patients or 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. HOMECARE SPECIFIC Responsible for rendering professional nursing care to patients in their home by assessing, developing, implementing and evaluating home nursing care needs on individual and continuing basis of assigned patients in keeping with agency policies and procedures and external regulations.

• Works closely with physicians in all specialties to develop and execute patient care plans and coordinate communications & referrals with care team members & settings of care on behalf of patients.
• Reviews risk stratification assessments to identify at-risk patients and ensures individualized care planning for identified high-risk patients.
• Identifies strategies to improve the health literacy of the patient, family, and other caregivers as appropriate, promoting patient engagement, self-management, and shared decision-making.
• Works with physicians, clinical staff, and health coach (where applicable) to develop and maintain appropriate education on, and compliance with, clinical protocols.
• Assists office staff in improving work flows to optimize the use of electronic medical records and clinical data tracking systems, providing for assessment of clinical outcomes & reporting.
• Communicates with primary care and applicable specialty physician's offices regarding patient status, gaps in care, and follow up needs, utilizing clinical protocols where applicable.
• Networks with local/community services to identify additional resources to support patients and their families.
• Assists with departments Quality / Performance Improvement Activities.
• Document in accordance with documentation guidelines and regulatory standards as well as provide hand-off patient information summaries to the next setting of care on the following: Patient/Member Engagement activities to include assessments, care plans, problems, goals, and interventions.
• Team member coordination, collaboration & Supervision (LPN, CMA, SW)( where applicable)
• Embedment or Travel to various office settings (i.e. physician practice, patient home, acute/post-acute settings).
• 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.

Education, Knowledge, Skills and Abilities Required:

• Associate's Degree in Nursing.
• Familiarity with Utilization Management Criteria, PQRS, HEDIS, Meaningful Use, Patient-Centered Medical Home, or 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).
• Excellent written and verbal communication skills.
• Proficient computer skills that include but are not limited to Microsoft Office and/or Google Suite platforms.

• Bachelor's Degree in Nursing.

• NJ State Professional Registered Nurse License.

• Professional Certification (CCM).

If you feel that the above description speaks directly to your strengths and capabilities, then please apply today!