Registered Nurse, Community Based Care Management in Tinton Falls, NJ

Overview Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community. Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change. 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. Responsibilities A day in the life of a RN, Community Based Care Management at Hackensack Meridian Health includes: • 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. Qualifications 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. Education, Knowledge, Skills and Abilities Preferred: • Bachelor's Degree in Nursing. Licenses and Certifications Required: • NJ State Professional Registered Nurse License. Licenses and Certifications Preferred: • Professional Certification (CCM). If you feel that the above description speaks directly to your strengths and capabilities, then please apply today! Starting Minimum Rate Minimum rate of $106,329.60 Annually Job Posting Disclosure HMH is committed to pay equity and transparency for our team members. The posted rate of pay in this job posting is a reasonable good faith estimate of the minimum base pay for this role at the time of posting in accordance with the New Jersey Pay Transparency Act and does not reflect the full value of our market-competitive total rewards package. The starting rate of pay is provided for informational purposes only and is not a guarantee of a specific offer. Posted hourly rates may be stated as an annual salary in the offer and posted annual salaries may be stated as an hourly rate in the offer, depending on the level and nature of the job duties and credentials of the candidate. The base compensation determined at the time of the offer may be different than the posted rate of pay based on a number of non-discriminatory factors, including but not limited to: Labor Market Data: Compensation is benchmarked against market data to ensure competitiveness. Experience: Years of relevant work experience. Education and Certifications: Level of education attained, including specialized certifications, credentials, completed apprenticeship programs or advanced training. Skills: Demonstrated proficiency in relevant skills and competencies. Geographic Location: Cost of living and market rates for the specific location. Internal Equity: Compensation is determined in a manner consistent with compensation ranges for similar roles within the organization. Budget and Grant Funding: Departmental budgets and any grant funding associated with the job position may impact the pay that can be offered. Some jobs may also be eligible for performance-based incentives, bonuses, or commissions not reflected in the starting rate. Certain positions may also be eligible for shift differentials for work performed on evening, night, or weekend shifts. In addition to our compensation for full-time and part-time (20+ hours/week) job positions, HMH offers a comprehensive benefits package, including health, dental, vision, paid leave, tuition reimbursement, and retirement benefits.