Position Summary

Provides the collaborative process of care coordination through the following: assessment, planning, facilitation and advocacy for healthcare options and services to meet the health care 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

1. 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.

2. Utilizes required software technologies via the EMR to effectively communicate with both the Internal and External interdisciplinary healthcare teams.

3. 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 in the patient's EMR.

4. 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.  

5. Engages patients/families/caregivers in discharge planning process and assures a safe and effective discharge plan and transition of care while promoting self-management of chronic disease conditions.

6. Supports organizational objectives of Service Excellence, Critical Success Factors and High Reliability Organization standards.

 

Qualifications

Minimum Education:

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, be continuously enrolled and complete within 5 years of hire date or internal RN promotion date.

Preferred:

Bachelor's degree in Nursing

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

Required:

Three years of medical/surgical hospital based direct patient care experience

Preferred:

Five years of medical/surgical hospital based direct patient care experience and Care coordination or Case Management experience.

License, Registry or Certification:

Required:

Current NJ RN licensure

Preferred:

Certification in Specialty or Case Management Certification 

Knowledge, Skills and/or Abilities:

Required:

Strong verbal, written, organizational and interpersonal communication skills.

Ability to develop and maintain collaborative relationships with the interdisciplinary team

Comprehensive Assessment and Care/Discharge Planning

Demonstrate knowledge-base in patient care evaluation and assessment, patient/family/caregiver engagement, insurance/benefits for services, community resources and research and evaluation techniques for quality improvement.

Ability to learn software applications in the EMR and new technologies.