Responsible for assisting patients referred to AHS for assistance in accessing and utilizing health care resources due to their complex chronic illness and co-occurring psychiatric diagnoses. Improves health outcomes through coordinating care, educating patients, building trust between patients and medical practitioners, and enhancing communication and the continuity of care. Teaches, counsels and monitors patients on health issues relevant to their care. Consults with other health care team members to coordinate the services of patient education, preventive care and disease management.
Principal Accountabilities:
1. Performs care coordination for high-risk patients to ensure continuity of care and quality healthcare delivery across the care continuum.
2. Utilizes established clinical pathways to facilitate comprehensive and consistent chronic disease specific condition education.
3. Maintains patient confidentiality with all activities in the Care Coordination Program.
4. Provides care coordination by collaborating with a multidisciplinary team.
5. Promotes patient adherence to individualized plan of care.?
6. Collaborates and communicates patient findings to primary care provider, Care Coordination Team, and healthcare providers, and identified care-partner(s) as appropriate across various health care settings via timely, accurate, and clear communication modalities.
7. Utilizes evidence-based risk-stratification tools to proactively assess chronically-ill population, identify patients at risk for disease-related sequelae and deliver patient-centered evidence-based interventions to prevent future progression or exacerbation of illness.
8. During exacerbation, intervenes at the earliest opportunity through multidisciplinary collaboration with all members of the care team, including patient and identified care-partner to return the patient safely to optimal level of health/function in an optimal setting.
9. Identifies opportunities for health promotion and disease prevention. Identifies Social/Behavioral Health needs which impacts patient's outcomes and appropriately refers to Social Work team member.
10. Assesses/Refers patients to available community support services as deemed necessary.?
11. Collaborates with multidisciplinary team to develop innovative strategies addressing the needs of the population.?
12. Assesses the self-care needs of the high-risk patient and identifies need for additional support. Provides patient/care-partner(s) education regarding prevention/recognition/treatment of disease exacerbation and promotes self-management of chronic condition and comorbidities.
13. Participates in evidence-based research, performance improvement, and quality initiatives as appropriate.?
14. Assumes responsibility and accountability for professional development and pursues ongoing continuing education to deliver patient-centered care. Demonstrates successful completion of ongoing proficiency and compliance with regulatory requirements.
15. Assists in orientation and training of new staff as requested. ?Participates in provider outreach and education. Serves as a community resource, providing educational programs for the community.
16. Collaborates with AHS leadership on additional tasks as requested.? ?
Required:
1. Graduate of an accredited Nursing Program; BSN required
2. Current NJ Registered Professional Nursing license required.
4. Current PA and NY Nursing license a plus.
5. Minimum 5 years of clinical experience as a Registered Professional Nurse.
Preferred:
1. Community health experience and knowledge of community healthcare resources preferred
2. CCM certification preferred.
At Atlantic Health, our promise to our communities is; Anyone who enters one of our facilities will receive the highest quality care delivered at the right time, at the right place, and at the right cost. This commitment is also echoed in the respect, development and opportunities we give to our more than 22,000 team members. Headquarters in Morristown, New Jersey, we are one of the leading non-profit health care systems in the nation. Our facilities and sites of care include:
We have more than 900 community-based healthcare providers affiliated through Atlantic Medical Group.
We have received awards and recognition for the services we have provided to our patients, team members and communities. Below are just a few of our accolades:
Atlantic Health offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members. Offerings vary based on role level (Team Member, Director, Executive). Below is a general summary, with role-specific enhancements highlighted:
Team Member Benefits
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Note: In Compliance with the NJ Pay Transparency Act (effective Sunday, June 1, 2025), all job postings will include the hourly wage or salary (or a range), as well as this summary of benefits. Final compensation and benefit eligibility may vary by role and employment status and will be confirmed at the time of offer.
EEO STATEMENT
Atlantic Health, Inc. is an equal employment opportunity employer and federal contractor or subcontractor and therefore abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, citizenship status, disability, age, genetics, or veteran
Atlantic Health is at the forefront of medicine, setting standards for quality health care in New Jersey, Pennsylvania and the New York metropolitan area. Headquartered in Morristown, NJ, we are a leading non-profit health care system, powered by a passionate workforce of 24,000 team members dedicated to building healthier communities. Atlantic Health serves more than half the state of New Jersey, including 14 counties and 7.5 million people and provides care for the full continuum of health needs across a wide array of settings, including dozens of outpatient and urgent care locations, Atlantic Rehabilitation Institute, Atlantic Health Goryeb Children’s Hospital, Atlantic Visiting Nurse and Atlantic Mobile Health. Our acute care hospitals include:
• Atlantic Health Morristown Medical Center, Morristown, NJ
• Atlantic Health Overlook Medical Center, Summit, NJ
• Atlantic Health Newton Medical Center, Newton, NJ
• Atlantic Health Chilton Medical Center, Pompton Plains, NJ
• Atlantic Health Hackettstown Medical Center, Hackettstown, NJ
• Atlantic Health CentraState Medical Center, Freehold, NJ
We receive awards and recognitions for our extraordinary care and our supportive workplace culture. Below are just a few of our accolades:
• 100 Best Companies to Work For® - Great Place to Work® and FORTUNE® magazine for 16 years
• One of the 100 Best Workplaces for Millennials: Great Place to Work® and FORTUNE® magazine
• America’s Greatest Workplaces in Health Care: Newsweek
• America’s Greatest Workplace for Women, Gen Z and Inclusion and Diversity: Newsweek
• Best Places to Work in Healthcare – Modern Healthcare
• 150 Top Places to work in Healthcare – Becker’s Healthcare
• Best Employers for Workers over 50 – AARP
• Gold-Level "Well Workplace": Wellness Council of America (WELCOA)
• System for Change Award from Practice Greenhealth
