Full Time Position: 40 hrs/week 8am-4:30pm; Mon-Fri with 1 Saturday/month
Provides the collaborative process of care coordination through the following: assessment, planning, facilitation and advocacy for healthcare options and services to meet the healthcare needs of patients. Utilizes resources to promote quality, cost effective outcomes, as the patient transitions through the healthcare continuum. Collaborates, coordinates and communicates the discharge plan to facilitate seamless, safe and effective transitions of care.
Primary Position Responsibilities
Provides ongoing individualized assessment, planning and care coordination for assigned patients during the hospital stay and documents activities in all appropriate areas of the patient's electronic medical record. Engages patient/family/caregiver in the care coordination process and discharge plan. Updates changes to plan as condition changes and communicates changes to the healthcare team.
Utilizes required software technologies via the EMR to effectively communicate with both the internal and external interdisciplinary healthcare team.
Plans and facilitates a safe discharge plan with input from the patient/family/caregiver and healthcare team, while coordinating benefits and utilization of outpatient treatments/therapies, specialty and primary care practices and community resources, with full optimization of the integrated delivery healthcare system. Documents Plan of Care in the patient's EMR.
Effectively communicates the care coordination plan to patients/families/caregivers, interdisciplinary team members, and collaborates with out-patient Care Coordinators to ensure a seamless transition of care, in a timely manner.
Engages patients/families/caregivers in evidence-based self-management of chronic disease conditions to promote optimal outcomes and avoid rehospitalization.
Supports organizational objectives of Service Excellence, Critical Success Factors and High Reliability Organization standards.
Required: All hires after July 2012 are required to have a Bachelor's Degree in Nursing. OR if Associates Degree or Diploma, RN must provide proof of enrollment in a BSN program prior to hire and complete program by December 2020.
Minimum Years of Experience:
Required: Five years of medical/surgical hospital based direct patient care experience
License, Registry or Certification:
Required: Current NJ RN licensure. Case Management Certification or must obtain within two years of hire.