Comprehensive Outpatient RN Care Manager

Community Health Center - The Federally Qualified Health Centers of the VNA of Central Jersey

Community Health Center (CHC) offers comprehensive, community based, preventive, primary care and wellness services for New Jersey residents of all ages at four convenient locations.CHC health care services are designed to meet the specific needs of the entire family – from annual check-ups and immunizations to sick visits, mental health counseling and critical prenatal care. 

This exciting  role is responsible for improving the quality of delivered healthcare through identification of high-acuity patients and at risk populations. Development, implementation, monitoring, and tracking of patient care plans (as well as related data such as referral sources) at the individual and population level, through shared patient decision making, provider collaboration, and community resources while utilizing evidence based interventions to improve patient outcomes.

Principal Responsibilities:

• Supports organization's mission by striving for excellence in all aspects of their job with a focus on positive interpersonal relationship with co-workers.
• Promotes timely access to appropriate care, utilizing a patient centered, culturally sensitive, team-based approach.
• Identifies patients’ unmet healthcare needs using primary care and disease specific standards
• Creates and promotes adherence to care plans, developed in coordination with the patient and Provider.
• Assists care team in in identifying patient care improvement needs and measuring continuous quality improvement.
• Engages patients in shared decision making in their care and shared responsibility in their outcomes with the goal of enhancing their health and wellbeing as well as increasing patient satisfaction and reducing health care costs.
• Increases comprehension through culturally and linguistically appropriate health education.
• Connects patients to relevant community resources with the goal of enhancing the patient’s health while reducing emergency room utilization and hospital admissions.
• Cultivates and supports primary care and specialty provider co-management with timely communication, inquiry, follow up, and integration of information into the patient’s health care plan.
• Collaborates with Patient Care Coordinators to facilitate patient appointments and obtain prior authorizations to assure patient access to appropriate medications, equipment and service to ensure that the patients specific healthcare needs are met.
• Develops relationship with collaborating healthcare institutions, medical specialists, and community resource partners to support effective and efficient care of patients while creating a medical neighborhood to better serve at risk populations and facilitate seamless transitions of care.
• Uses the electronic health record to manage data regarding both individuals and populations including disease registries and creating reports showing trends and points in time in terms of process and outcome measures.
• Works independently, multitasks, and takes initiative to ensure patient adherence to medical plan of care, including all appropriate preventative and disease-specific screenings, interventions, treatment goals, and contact schedules.
• Analyzes workflows, both clinical and electronic health record, to improve patient outcomes and works with the Director of Clinical of Quality and Education, and clinical support team to document and implement standardized workflows.
• Participates in outreach to the community regarding CHC programs and services.
• Responds to insurance plan requests for medical records of a clinical nature in collaboration with medical records supervisor.
• Collaborates with Clinical Quality Director to ensure optimal success with shared savings payer plans.
• Actively participates in office-wide and team huddles to prepare for work of the day including ensuring availability of necessary records and consult reports.

The ideal candidate for this position will have the following qualifications:

• Registered Nurse, BSN preferred
• Previous population health or care coordination experience preferred. Certified Case Management (CCM) preferred
• 5+ years clinical nursing experience with either ambulatory care and/or community health experience preferred
• Excellent verbal and written communication skills and interpersonal skills required
• Computer proficiency, data analysis skills,  MS office required, including advanced Excel; or nursing informatics degree, preferred
• Bilingual preferred, Spanish and/or French Creole
• Car and valid N.J. driver’s license

Working Conditions/Physical Demand: Working indoors.  Exposure to blood, body fluids and communicable diseases. Sitting, fine motor hand movement, standing, walking, lifting 40 pounds, pushing, reaching, pulling; working with Thermometer, sphygmomanometer, stethoscope, otoscope, opthalmoscope, needles, syringes, EKG machine, venipuncture equipment, other diagnostic equipment, spirometry treatment, culture mediums, telephone, fax, photocopier, computer, printer.

This job description is intended to convey information essential to understanding the scope of the Comprehensive Outpatient RN Care Manager position and it is not intended to be an exhaustive list of experience, skills, efforts, duties, responsibilities, or working conditions associated with the position.