**Overview** Our team members are the heart of what makes us better. At **Hackensack Meridian** **_Health_** we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community. Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change. The **Care Coordinator for Family Medicine** determines the needs of high-risk patients and provides telephonic and/or in-person education related to positively impacting their quality of life and clinical outcomes. Partners with providers, staff, patients, and caregivers. Visits patients in the hospital, the office, the nursing home, or the home as needed. Acts as an advocate for these patients; links them to other care team members as needed to help patients gain knowledge of their chronic conditions and identifies community resources for continued growth toward a maximum level of independence. Collaborates with providers to coordinate and manage patients as needed. An active member in a patient-centered team approach in the care of patients and families. Works collaboratively with all team members in achieving shared goals with a consistent focus on quality care. **Responsibilities** A day in the life of a **Care Coordinator for Family Medicine** at **Hackensack Meridian** **_Health_** includes: + Participates in daily patient reviews. Maintains communication with other team members as well as office staff and providers. Communicates regularly with assigned patients either by telephone or with face-to-face encounters. Monitors patients' health status and communicates the self-management skills needed to maintain the highest level of function. Communicates issues and concerns back to providers and or office staff. + Collects health history data from patient, family, PCP, office staff, and other health care team members as needed. Utilizes critical thinking to identify the patients' bio-psychosocial, spiritual, cultural, environmental, and educational needs. + Collaborates with other members of the team as well as outside resources when needed to develop a comprehensive plan of care incorporating current diagnosis, interventions, beneficiary self-management skills, and educational needs. Takes into consideration all chronic conditions when creating the plan of care. + Documents all data and findings consistently and comprehensively under regulatory requirements. Completes documentation in the EMR on all patients. Focuses on the Rising Risk population, determines Health Care needs, and enters patients into Disease Coordination programs when applicable. + Write Care Plans in EPIC Healthy Planet for high-risk patients being care managed. + Other duties and/or projects as assigned. + Adheres to HMH Organizational competencies and standards of behavior. **Qualifications** **Education, Knowledge, Skills and Abilities Required:** + Graduate of accredited Registered Nursing Program. + Minimum 2-3 years experience in managed care or health education/coaching is preferred. + Must be able to prioritize, plan and handle multiple tasks/demands simultaneously. + Requires communication skills to engage patients/families over the phone and in person. + Experience working with large EMR/Health systems + Experience using Microsoft Word, Excel, and Outlook. **Education, Knowledge, Skills and Abilities Preferred:** + RN Degree. **Licenses and Certifications Required:** + NJ State Professional Registered Nurse License. If you feel that the above description speaks directly to your strengths and capabilities, then please apply today! **Job ID** _2025-159647_ **Department** _Family Medicine Center_ **Site** _JFK Medical Center_ **Job Location** _US-NJ-Edison_ **Position Type** _Full Time with Benefits_ **Standard Hours Per Week** _40_ **Shift** _Day_ **Shift Hours** _Day_ **Weekend Work** _No Weekends Required_ **On Call Work** _No On-Call Required_ **Holiday Work** _No Holidays Required_