Director of Care Management 

Visiting Nurse Association of Central Jersey Community Health Center Inc. (CHC) 

 

The Director of Care Management is responsible for the daily programmatic oversight of the care management program and the assigned care management team. The Director of Care Management oversees the RN care managers, the patient navigators and patient care coordinators to ensure the overall provision and coordination of care management services to CHC patients and ensures ongoing communication across the Interdisciplinary Care Team. The Director of Care Management provides individual and group supervision to assigned staff and evaluates all supervisees on a regular and timely basis.

 

This team is responsible for improving the quality of delivered healthcare through identification of  high-acuity patients and at risk populations at the Visiting Nurse Association of Central Jersey Community Health Center Inc. (CHC)  Development, implementation and monitoring of patient care plans at the individual level as well as the population level through shared patient decision making, provider collaboration, and community resources while utilizing evidence based interventions to improve patient outcomes.

• Supports organization’s mission by striving for excellence in all aspects of their job with a focus on positive interpersonal relationship with co-workers
• Responsible for assisting and developing a successful and cohesive Care Management team, with high level of productivity and accuracy to achieve the team’s overall performance metrics.
• Identifies training needs of Care Management team including training materials, competency checklist, and orientation checklists necessary to meet education and training needs of CM staff.
• Ensures proper staffing and coverage within the Care Management Team
• Analyzes workflows, both clinical and electronic health record, to improve patient outcomes and works with Director of Clinical Services, Chief Medical Officer and NextGen Clinical Support team to document and implement standardized workflows.
• Tracks performance of clinical outcomes, including creating detailed monthly dashboards by site and provider panels.
• Promotes timely access to appropriate care, utilizing a  patient centered, culturally sensitive, team-based approach
• Identifies patient’s unmet healthcare needs using primary care and disease specific standards
• Ensures the creation of and promotes adherence to care plans, developed in coordination with the patient and primary care provider
• Ensures the Care Coordination team engages patients in shared decision making in their care and shared responsibility in their outcomes with the goal of enhancing their health and well being as well as increasing patient satisfaction and reducing health care costs.
• Ensures patients receive culturally and linguistically appropriate health education
• Ensures patients are provided with connections 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
• Develops relationship with collaborating healthcare institutions,  medical specialists, and community resource partners to support effective and efficient care of CHC patients while creating a medical neighborhood to better serve at risk populations and facilitate seamless transitions of care
• Ensures that systems are in place to facilitate patient appointments, and obtain prior authorizations to assure patient access to appropriate medications, equipment and services to meet patients’ specific healthcare needs.
• 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.
• Participates in the Center’s standing committees as appropriate

• 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 NJ driver’s license

Visiting Nurse Association of Central Jersey Community Health Center Inc. (CHC) provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.