Job Summary:

Supports care coordination efforts for adult patients with moderate to complex illness, in the primary care setting, under minimal supervision. In partnership with the practice leadership team, including Clinicians, LCSWs, CBHMs and Practice Manager leads care management within the team through process improvement, workflow redesign, providing assistance with training, and delegating to other members of the team. Serves in an expanded health care role to collaborate with specialists, members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services. Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient’s health status. Integrates evidence-based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care.

Position Responsibilities:

Collaborates with practice leadership to lead practice transformation efforts and population health initiatives.

Collaborates with Practice Team to execute Daily Clinical Huddle: Reviews General Risk Scores for patients on the schedule, ED / IP tracking and follow up, Gaps in Care etc..

Leads care coordination efforts:

• Oversight for Practice Risk Stratification.
• Transitions of Care: Manages outreach, scheduling and follow up.
• Collaborates with other case/disease managers as applicable.
• Coordinates & performs Medicare Annual Wellness Visits.

Coordinates Care Management Efforts:

• Creates & Reviews Care Plans with patients and family members, in order to provide Episodic and/or longitudinal care management.
• Coaches the patient /care giver to meet patient centered individual plan of care goals.
• Assesses health literacy of patients, and supports Medical Assistants with skill development for patient assessment.
• Leads health coaching and motivational interviewing efforts; supports Medical Assistants with skill development.
• Develops and implements patient education materials.
• Maintains a list of local self-management support resources.
• Coordinates with social worker with regard to community resources.

Serves as a clinical resource to practice staff.

Other duties as assigned.

Position Qualifications Required:

Required Experience:

1-3 years of experience in care coordination. Experience working in physician practice preferred.

Required Education:

Graduate of an accredited school of nursing, BSN preferred

Training / Certification / Licensure:

Must have current NJ license, current CPR certification.