Outpatient RN Case Management in Flemington, New Jersey at Hunterdon Health Care System

Outpatient RN Case Management

Position Summary

Under the direction of the Medical Director and Practice Manager, the Registered Nurse (RN) collaborates with the health care team to skillfully provide and facilitate the coordination of individualized, high-quality patient care. The RN serves as a clinical leader within the practice, supporting efficient operations, patient access, and optimal clinical outcomes. The RN will be motivated, energetic, and an empathetic communicator who is passionate about delivering the highest quality of care.

The Registered Nurse – Outpatient Psych / Behavioral Health & Case Management provides comprehensive clinical nursing care and care management services to patients receiving outpatient behavioral health services. The RN integrates direct patient care with case management, care coordination, patient education, chronic disease management, and behavioral health support to improve clinical outcomes, enhance the patient experience, and reduce avoidable utilization.

This position collaborates closely with psychiatrists, advanced practice providers, therapists, primary care providers, specialists, hospitals, community agencies, and caregivers to coordinate patient-centered care across the continuum. The RN utilizes evidence-based nursing practice, trauma-informed care principles, motivational interviewing, and population health strategies to support patients with behavioral health conditions and coexisting medical illnesses.

Primary Position Responsibilities

1. Patient Care:

a. Delivers direct patient care within the scope of licensure and in accordance with HMG policy and protocols, including point of
care testing, EKG’s, phlebotomy and medication/vaccine administration/long-acting injectable medications..
b. Prioritizes patient care by implementing physician orders and nursing procedures. Recognizes important changes in patient
condition and reacts appropriately.
c. Executes care understanding standing orders and clinical protocols, applying independent nursing judgement and critical
thinking.
d. Triages patient calls and symptoms prioritizing care needs and scheduling appropriately to clinical judgement
i. Identifies patients requiring crisis intervention and initiates appropriate emergency response procedures while
coordinating with providers and crisis services.

e. Manages Nurse Visit schedule and effectively communicates problems, concerns or issues to the Office Supervisor/Manager
appropriately and promptly
f. Patient Education:
i. Provides patient and family education on disease management, medications, and preventive care
ii. Assesses health literacy and adapts communication accordingly

2. Documentation:

a. Ensures accurate, timely documentation in the EHR
b. Ensures proper labeling, handling and documentation for patient specimens
c. Assures all patients are correctly identified prior to providing and/or documenting care
d. Monitors and Documents storage conditions (medications, vaccines) and take corrective action as needed.

3. Clinical Leadership and Operations:

a. Serves as a clinical resource and provides oversight and delegation to unlicensed staff.
b. Attends annual clinical facilitator training to support staff onboarding, training, competency validation, and ongoing
education
c. Manages clinical supply and vaccine inventory in accordance with Centers for Disease Control and Prevention guidelines
d. Leads and/or participates in daily safety huddles, staff meetings, and process improvement initiatives.
e. Supports infection prevention and control protocols.

4. Professional Responsibility:

a. Practices in accordance with the New Jersey Board of Nursing standards
b. Appropriately adheres to universal safety precautions when administering vaccines, medications and during disposal of
medical waste
c. Maintains responsibility for own professional development through active participation in in-services and/or continuing
education programs
d. Actively embraces and integrates High Reliability Organization (HRO) principles into daily practice, including maintaining
situational awareness, speaking up for safety, and participating in process improvement initiatives. Contributes to a culture of
transparency, accountability, and continuous learning.
e. Other duties as required

5. Case Management

a. Coordinates care among behavioral health providers, primary care, specialty care, emergency departments, hospitals, skilled
nursing facilities, and community agencies.
b. Performs transition-of-care outreach following emergency department visits, psychiatric hospitalizations, and medical
admissions.
c. Monitors high-risk patients through telephone outreach, virtual visits, patient portal communication, and scheduled follow-
up.
d. Coordinates referrals for counseling, substance use treatment, social services, housing assistance, transportation, financial
assistance, vocational programs, and community resources.
e. Assists patients in overcoming barriers to medication adherence, appointment compliance, and treatment engagement.
f. Collaborates with pharmacies, insurance carriers, and providers to facilitate medication prior authorizations and access to
specialty medications.
g. Coordinates with family members and caregivers when appropriate and consistent with patient consent and privacy
regulations.
h. Facilitates multidisciplinary case conferences for complex patients.
i. Maintains accurate care management documentation and patient registries.
j. Supports patients enrolled in Chronic Care Management (CCM), Behavioral Health Integration (BHI), Collaborative Care Model
(CoCM), Transitional Care Management (TCM), and other value-based care programs.
k. Tracks and monitors quality metrics including depression screening, suicide risk assessment, follow-up after hospitalization,
medication adherence, and preventive health measures.

l. Identifies patients requiring proactive outreach based upon quality measures and risk stratification.
m. Promotes continuity of care across healthcare settings.
n. Supports organizational initiatives focused on population health and value-based reimbursement.
o. Participates in quality improvement projects designed to improve patient outcomes and patient satisfaction.

Work Contact Group (Internal/External)

Physicians and residents at various levels of training, patients, patient’s families, outpatient office staff personnel, some HMC dept.
personnel, representatives from laboratory pharmaceutical companies.

Reporting Relationships

Reports to (position):

Nurse Manager, Nurse supervisor and/or Practice Manager / Director

Supervises (position(s):

Supervises-clinical staff in absence of Nurse supervisor/manager

Qualifications

Minimum Education:

Required:

Associate’s Degree in Nursing

Preferred:

Bachelor’s Degree in Nursing

Minimum Years of Experience (Amount, Type and Variation):

Required:

1 year of clinical experience

Preferred:

2 years of clinical experience

License, Registry or Certification:

Required:

Graduate from an accredited nursing school; current New Jersey RN license, CPR certified ,or obtain certification within
6 months

Preferred:

None

Knowledge, Skills and/or Abilities:

Required:

Good communication and interpersonal skills, decision making ability, telephone etiquette, detail and multitasking
oriented, ability to handle a high volume of patients

Preferred:

None

Hunterdon Health is committed to providing a competitive benefit package to our employees. Benefit offerings vary based on status and may include but not be limited to medical, dental, vision, family forming, paid time off, tuition reimbursement, and retirement savings.

The hiring range listed is the potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement. When determining an applicant’s hourly rate and/or base salary, several factors may be considered as applicable (e.g., years of relevant experience, education, internal equity, and specialty).