Complex Care Coordinator (RN), Full Time Days, 8a - 4p, Corporate Headquart at Atlantic Health

Morristown, New Jersey, United States -

Full Time

Start Date

Immediate

Expiry Date

19 Oct, 26

Salary

73.56

Posted On

21 Jul, 26

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Care Coordination, Chronic Disease Management, Patient Education, Risk Stratification, Multidisciplinary Collaboration, Clinical Pathways, Patient Advocacy, Case Management, Health Promotion, Disease Prevention, Psychiatric Diagnosis Support, Community Resource Navigation

Industry

Hospitals and Health Care

Description

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.? ? 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: * 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 Goryeb Children's Hospital, Morristown, NJ * Atlantic Health CentraState Healthcare System, Freehold, NJ * Atlantic Medical Group * Atlantic Visiting Nurse * Atlantic Mobile Health * Atlantic Rehabilitation 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: * Chosen for 17 years by Fortune as one of the magazine’s “100 Best Companies to Work For." * Atlantic Health Morristown and Atlantic Health Overlook Named by Newsweek as two of the “World’s Best Hospitals” in 2026. * Atlantic Health Morristown and Atlantic Health Overlook ranked within the top three hospitals in New Jersey by U.S. News & World Report’s 2025-2026 Best Hospital rankings. * Atlantic Health scored four “A” grades by The Leapfrog Group in its Fall 2025 Hospital Safety Grades, performance measures reflecting errors, accidents, injuries and injections, as well as systems hospitals have in place to prevent harm. * Atlantic Health Morristown and Atlantic Health Overlook are New Jersey's only hospitals to be named among America's 50 Best hospitals by Healthgrades in 2026. * Named by Becker's Healthcare as one of the "165 Top Places to Work in Healthcare – 2026. * Atlantic Health Morristown, Atlantic Health Overlook, Atlantic Health Chilton and Atlantic Health Newton all Forbes Top Hospitals for 2026. * Named by Newsweek as one of America’s Greatest Workplaces for Inclusion & Diversity 2025. * Atlantic Health rated LEVEL 9 - 2025 CHIME Digital Health Most Wired. 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 * 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 ____________________________________________ 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

Responsibilities

Coordinates care for high-risk patients with complex chronic illnesses and psychiatric diagnoses to improve health outcomes and continuity of care. Collaborates with multidisciplinary teams to provide patient education, monitor health issues, and prevent disease exacerbation.