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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 System, 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 20,000 team members. Headquartered 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:

+ Morristown Medical Center, Morristown, NJ

+ Overlook Medical Center, Summit, NJ

+ Newton Medical Center, Newton, NJ

+ Chilton Medical Center, Pompton Plains, NJ

+ Hackettstown Medical Center, Hackettstown, NJ

+ Goryeb Children's Hospital, Morristown, NJ

+ CentraState Healthcare System, Freehold, NJ

+ Atlantic Home Care and Hospice

+ Atlantic Mobile Health

+ Atlantic Rehabilitation

We also have more than 900 community-based healthcare providers affiliated through Atlantic Medical Group. Atlantic Accountable Care Organization is one of the largest ACOs in the nation, and we are a member of AllSpire Health Partners.

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:

+ 100 Best Companies to Work For ® and FORTUNE® magazine for 15 years

+ Best Places to Work in Healthcare - Modern Healthcare

+ 150 Top Places to work in Healthcare - Becker's Healthcare

+ 100 Accountable Care Organizations to Know - Becker's Hospital Review

+ Best Employers for Workers over 50 - AARP

+ Gold-Level "Well Workplace": Wellness Council of America (WELCOA)

+ One of the 100 Best Workplaces for “Millennials” Great Place to Work® and FORTUNE® magazine

+ One of the 20 Best Workplaces in Health Care: Great Place to Work® and FORTUNE® magazine

+ Official Health Care Partner of the New York Jets

+ NJ Sustainable Business

Since 1932, Newton Medical Center has been providing care to the people of Sussex and warren counties in New Jersey, Pike County in Pennsylvania and southern Orange County in New York. We are home to the Center for Breast Health, the only one of its kind in Sussex County, addressing all of a woman’s breast health needs with state-of-the-art technology, resources, education, support and follow-up care. Newton Medical Center recently achieved the American Nurses Credentialing Center’s Pathway to Excellence designation and is one of a select few health care facilities in New Jersey accredited by the Intersocietal Accreditation Commission (IAC) in all three echocardiography procedures: adult transthoracic, adult transesophogeal and adult stress.

Atlantic Health System 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

+ Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full-time and part-time team members)

+ Life & AD&D Insurance.

+ Short-Term and Long-Term Disability (with options to supplement)

+ 403(b) Retirement Plan: Employer match, additional non-elective contribution

+ PTO & Paid Sick Leave

+ Tuition Assistance, Advancement & Academic Advising

+ Parental, Adoption, Surrogacy Leave

+ Backup and On-Site Childcare

+ Well-Being Rewards

+ Employee Assistance Program (EAP)

+ Fertility Benefits, Healthy Pregnancy Program

+ Flexible Spending & Commuter Accounts

+ Pet, Home & Auto, Identity Theft and Legal Insurance

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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 System, 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 status.