About Our Company

We’re a physician-led, patient-centric network committed to simplifying health care and bringing a more connected kind of care.

Our primary, multispecialty, and urgent care providers serve millions of patients in traditional practices, patients’ homes and virtually through VillageMD and our operating companies Village Medical, Village Medical at Home, Summit Health, CityMD, and Starling Physicians.

When you join our team, you become part of a compassionate community of people who work hard every day to make health care better for all. We are innovating value-based care and leveraging integrated applications, population insights and staffing expertise to ensure all patients have access to high-quality, connected care services that provide better outcomes at a reduced total cost of care.

Please Note: We will only contact candidates regarding your applications from one of the following domains: @summithealth.com, @citymd.net, @villagemd.com, @villagemedical.com, @westmedgroup.com, @starlingphysicians.com, or @bmctotalcare.com.

Job Description

Essential Job functions:

• Works with interdisciplinary care team to facilitate seamless patient engagement and transitions across the continuum of care.
• This position oversees daily reports and data analysis to improve patient outcomes.
• Performs daily reporting and navigation for new consults
• Engagement with the Urologist to properly identify candidates into the Bladder and Prostate Program
• Assumes responsibility to support the physicians working on the floor with in the scope of practice of an RN, performing IV’s and a preferred oncology background.
• Learns and understands the overall Care Coordination process and goals and uses this information to identify and address patient barriers to care and gaps in care.
• Determines and completes appropriate referrals. Serves as a liaison to providers, patients, and families for coordination of services.
• Collaborates with providers and other healthcare team members to facilitate coordination and transitions of care across the healthcare continuum to optimize clinical and financial outcomes.
• Documents appropriately in the electronic health record and any required patient tracking documents. Employs appropriate and timely use of tasking in the EHR. Maintains accurate and timely documentation. Ensures documentation meets current standards and policies.
• Participates in regular team meetings and patient review activities. Participates in departmental and organizational committees, as applicable.
• Develops relationships across broad organizational lines.
• Performs all care coordination/navigation activities across the continuum of care while adhering to the core values of patient confidentiality, privacy, safety, advocacy, and adhering to ethical, legal, and accreditation/regulatory standards.
• Delivers care coordination services within the scope of licensure in accordance with Summit Health policy.
• Assumes accountability to changing patient and/or organizational priorities. Ability and willingness to self-motivate, to prioritize and change processes to improve effectiveness and efficiency. Adapts to changing patient or organizational priorities.
• Assumes accountability for the quality of care.
• Ability to manage conflict, stress, and multiple simultaneous work demands in an effective and professional manner.
• Continually seeks new knowledge and learning regarding diabetes and chronic disease management, social determinants of health, and coordination of care.
• Other duties as assigned.

General Job functions:

Coordination of Care:

• Performs telephonic outreach to patients monthly, or more frequently as needed, following program enrollment, and assures that the appropriate follow up visits are scheduled.
• Performs comprehensive medication reconciliation quarterly and during telephonic outreach when changes are identified.
• Reinforcing and reviewing plan of care, patient education, and the prevention of unnecessary emergency room visits and hospital admissions.

Quality Improvement Initiatives:

• Participates in ongoing QA/QI initiatives to improve performance and patient outcomes.
• Demonstrates ability to compile patient data and prepare outcome analysis.
• Serves as a resource for all current and future quality improvement initiatives within the Endocrinology Department.

Competency, Training and Education:

• Demonstrates knowledge of Care Coordination and Transitions of Care requirements and standards.
• Ability to implement the workflows that are specific to the Bladder and Prostate Program
• Demonstrates the ability to effectively communicate and collaborate with care team members.
• Communicates effectively with patients to engage them in Coordination of Care outreach.
• Maintains core proficiencies /competencies as defined by the Genitourinary Department.
• Self-motivation, focus, ability to work independently with good time and task management.
• Willingness to establish effective working relationships with internal and external customers.
• Maintains a good working relationship within the department and with other departments.
• Ability to work well independently, while collaborating with other team members. Serves as a clinical resource person to staff.

• Demonstrates appropriate and timely use of the EMR, tracking tools, data, and communication platforms.
• Assists with special projects as assigned and completes them within the required timelines.
• Effectively communicates problems, concerns, or issues to the Clinical Manager and/or Providers appropriately and promptly.

• Provides updates to the patient’s PCP and communicates with family members as needed.

• Collects, tracks, trends, and reports clinical data, as needed, for Diabetes Program and initiatives.
• Other duties as required.

Physical Job Requirements:

• Physical mobility, which includes movement from place to place on the job, taking distance and speed into account.
• Physical agility, which includes ability to maneuver body while in place.
• Dexterity of hands and fingers.

• Endurance (e.g. continuous typing, prolonged standing/bending, walking).

Education, Certification, Computer and Training:

Required:

• Bachelor’s Degree from an accredited Nursing School
• Valid New Jersey RN License Required.
• Minimum of 2 years nursing experience in Oncology
• Valid Driver’s License required & proof of valid vehicle insurance (NJ Coverage limits required).
• Excellent written, verbal and listening community abilities. Communicate appropriately and clearly to staff and providers.
• Computer literacy, including, by not limited to, data entry, retrieval, and report generation.
• Proficient Microsoft Office 365 skills required.
• Ability to work remotely and to work well in a virtual environment.
• Meet technical requirements to work remotely.
• Experience with standard office equipment (phone, fax, copy machine, scanner, email/voice mail) required.

Travel:

• Travel required for offsite meetings and to clinical offices.

Pay Range: $80,000.00 – $100,100.00 Annual

The provided compensation range is based on industry standards and salary determinations will be made based on numerous factors including but not limited to years of experience and location of position.

About Our Commitment

Total Rewards at VillageMD

Our team members are essential to our mission to reshape healthcare through the power of connection. VillageMD highly values the critical role that health and wellness play in the lives of our team members and their families. Participation in VillageMD’s benefit platform includes Medical, Dental, Life, Disability, Vision, FSA coverages and a 401k savings plan.

Equal Opportunity Employer

Our Company provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to, and does not discriminate on the basis of, race, color, religion, creed, gender/sex, sexual orientation, gender identity and expression (including transgender status), national origin, ancestry, citizenship status, age, disability, genetic information, marital status, pregnancy, military status, veteran status, or any other characteristic protected by applicable federal, state, and local laws.

Safety Disclaimer

Our Company cares about the safety of our employees and applicants. Our Company does not use chat rooms for job searches or communications. Our Company will never request personal information via informal chat platforms or unsecure email. Our Company will never ask for money or an exchange of money, banking or other personal information prior to the in-person interview. Be aware of potential scams while job seeking. Interviews are conducted at select Our Company locations during regular business hours only. For information on job scams, visit, https://www.consumer.ftc.gov/JobScams or file a complaint at https://www.ftccomplaintassistant.gov/.