Nurse Care Coordinator

Vanguard is growing!? We have an exciting new opportunity in our Verona office.
Job Overview: The Care Coordinator (CC) is a key role in managing patient outcomes and quality initiatives in the primary care setting. The CC will work as part of a multidisciplinary health care team focused on coordination of patient-centered care and health coaching. The CC will concentrate on the needs of the most complex and high risk patients, implement work flows for managing care transitions, and provide population management for those with chronic diseases.
Major Responsibilities:
Work in collaboration with health care team and other CCs to identify, stratify and manage high risk patients, providing a care plan with self-management goals and documenting care activities in the EHR;
Contact and manage patients who experience a transition of care (inpatient stay or ED visit) within 48 hours, ensuring that medical, psychosocial and functional assessments are completed by the primary care physician or specialist after discharge, and appropriate follow-up appointments are scheduled;
Use data from various technology platforms including the EHR, hospital portals, and web applications to manage work flow;
Coordinate regular medication management with the patient/caregiver with specific attention to reconciliation after a transition of care;
Monitor that appropriate home care, hospice care or other ancillary services (DME, infusion services, etc) are in place and being delivered as directed by the primary care team;
Implement population management strategies for patients supported by technology-based tracking and incorporating best practices guidelines for preventive and disease screening;
Facilitate patient engagement activities through patient education which is focused on self-care, personal goal-setting, and partnering with the provider for best outcomes;
Mentor, coach and educate medical assistants (MA) in the areas of patient engagement, chronic disease management, using technology to enhance health management, professionalism, motivational interviewing skills and other activities focused on the growth and development of the MA staff;
Participate in specific committees, meetings and activities which promote the role of care coordination in a given site, in collaboration with the health care team;
Maintain professional competencies through attending continuing education courses and ensure that all licensure and certification credentials are consistently current.
Current, active, and unrestricted NJ Registered Nurse license, BS degree preferred
Certified Case Manager (CCM) certification preferred
3 years of case management experience in acute care, home care, or insurance company
3 years of direct patient care clinical experience
Critical Competencies:
Strong analytical skills using clinical judgment and case management experience
Persuasive interpersonal skills required; ability to influence others while motivating them to change
Able to prioritize and balance work responsibilities in a high volume environment
Takes initiative in finding solutions to difficult and/or sensitive problems
Effective communication skills with varied staff on the health care team

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