Ambulatory Transitions of Care Navigator Jobs in Borough of Tinton Falls at Hackensack Meridian Health

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 Ambulatory Transitions of Care Navigator is a member of the healthcare team and is responsible for coordinating, communicating and facilitating the care of patients discharged from HMH Hospitals and attributed to our Primary care Providers. The navigator is accountable for a designated case load determined by the daily selection of eligible patients (Non ACO/CIN Patient Population). They assess, plan, and facilitate, with patients/families and healthcare professionals involved in the patient's care to meet treatment goals, and arrange for the appropriate next steps. Oversees Coordination and handoff between acute & outpatient services.

Responsibilities

A day in the life of a Ambulatory Transitions of Care Navigator at Hackensack Meridian Health includes:

• Program eligibility and guidelines are established by the Network under the direction of the Ambulatory Quality and HMHMG operational executives. All patients who are discharged from an HMH hospital who are attributed to HMHMG Primary Care Providers (Non ACO/CIN populations) are currently considered for program enrollment. This may evolve as organizational needs change. All eligible patients will be enrolled.
• Outreach to the patient/family/caregiver to assess needs and develop an individualized needs assessment to plan.
• Facilitates communication and coordination between members of the health care team and involves the patient/family/caregiver in the decision making process, in order to minimize fragmentation of services, manage resources and remove barriers to the discharge plan of care.
• Develops a Transitions of Care (TOC) plan, in collaboration with the patient/family/caregiver, support services and healthcare team to facilitate the maximum benefit for each patient. Coordinates hand off between transitional care team members as needed; primary care provider, specialist, Community resources, Referrals, and or service providers, to meet patient Transitional care needs.
• Brings forth issues which impact patient`s transitions as well as the risk of readmission for discussion and resolution with the patient`s care team.
• Works collaboratively with all members of the multidisciplinary health care team and community partners for timely and appropriate transitions to the appropriate level of care.
• Maintains current and up to date information of community resources and refers patients to those community resources which will enhance patient`s life and clinical outcomes. Consults with other community agencies and committees to identify potential resources to support patients and their families. Will actively work with the Social Determinants of Health (SDOH) team to find community partners
• Documents and communicates information to the Multidisciplinary Team in order to coordinate and maximize care. The Electronic Health Record will reflect the needs of the patient, any education needed based on the patient's medical history, coordination of follow-up care, and referrals.
• Provides patients and families with resources and discharge care coordination options.
• Participates actively on appropriate workgroups, and/or meetings. Is a positive problem solver. Identifies and refers quality issues for review to the Manager.
• Reassesses periodically and evaluates against care goals and the plan of care and, when indicated, the plan or goals are revised.
• Medical records reflect that each patient`s TOC plan is re-assessed in response to changes in patient`s needs and Social Determinants of Health. Supports long-term patient wellness and helps prevent readmission by enrolling eligible patients in ongoing health management programs after their transition of care is complete.
• Completes all other necessary duties with attention to detail and in a timely manner.
• Collaborates with Hospital Utilization Review Nurses as needed.
• Other duties and/or projects as assigned.
• Adheres to HMH Organizational competencies and standards of behavior.

Qualifications

Education, Knowledge, Skills and Abilities Required:

• RN with a minimum of three years of clinical experience.
• Knowledge of Quality Improvement principles.
• Knowledge of Social Determinants of Health assessment
• Good working knowledge of benefit plans; Medicaid-HMOs, etc.
• Delegates and Supervises: Effectively delegates nursing tasks to LPNs and assistive personnel based on patient stability, complexity of the task, and Demonstrates ability to apply the Five Rights of Delegation (Right Task, Right Circumstance, Right Person, Right Direction/Communication, and Right Supervision/Evaluation).
• Strong organizational and problem solving skills.
• Excellent oral and written communication and interpersonal skills.
• Exceptional communication skills to enable communication and collaboration with physicians, patients, families and Care team staff.
• Excellent critical thinking skills.
• Ability to work in a fast paced team environment.
• Ability to prioritize and multitask.
• Ability to make sound, independent clinical judgements and act professionally under pressure.
• Demonstrate ability to provide age appropriate patient education, age appropriate written and verbal communication skills, cultural competency and customer service skills and health literacy.
• Excellent written and verbal communication skills.
• Proficient computer skills that include but are not limited to Google Suite and/or Microsoft Office platforms.

 

Education, Knowledge, Skills and Abilities Preferred:

• Bachelor of Science in Nursing (BSN).
• Experience with relevant systems; Google Docs, EPIC.

Licenses and Certifications Required:

• NJ State Professional Registered Nurse License.
• BLS AHA Basic Health Care Life Support HCP Certification.
• Valid Driver's License from a USA state.

Licenses and Certifications Preferred:

• ANCC Board certification.

 

If you feel that the above description speaks directly to your strengths and capabilities, then please apply today!     

Compensation
Minimum rate of $111,924.80 Annually

HMH is committed to pay equity and transparency for our team members. The posted rate of pay in this job posting is a reasonable good faith estimate of the minimum base pay for this role at the time of posting in accordance with the New Jersey Pay Transparency Act and does not reflect the full value of our market-competitive total rewards package.

The starting rate of pay is provided for informational purposes only and is not a guarantee of a specific offer. Posted hourly rates may be stated as an annual salary in the offer and posted annual salaries may be stated as an hourly rate in the offer, depending on the level and nature of the job duties and credentials of the candidate. The base compensation determined at the time of the offer may be different than the posted rate of pay based on a number of non-discriminatory factors, including but not limited to:

• Labor Market Data: Compensation is benchmarked against market data to ensure competitiveness.
• Experience: Years of relevant work experience.
• Education and Certifications: Level of education attained, including specialized certifications, credentials, completed apprenticeship programs or advanced training.
• Skills: Demonstrated proficiency in relevant skills and competencies.
• Geographic Location: Cost of living and market rates for the specific location.
• Internal Equity: Compensation is determined in a manner consistent with compensation ranges for similar roles within the organization.
• Budget and Grant Funding: Departmental budgets and any grant funding associated with the job position may impact the pay that can be offered.

Some jobs may also be eligible for performance-based incentives, bonuses, or commissions not reflected in the starting rate. Certain positions may also be eligible for shift differentials for work performed on evening, night, or weekend shifts.

In addition to our compensation for full-time and part-time (20+ hours/week) job positions, HMH offers a comprehensive benefits package, including health, dental, vision, paid leave, tuition reimbursement, and retirement benefits.

HACKENSACK MERIDIAN HEALTH (HMH) IS AN EQUAL OPPORTUNITY EMPLOYER

All qualified applicants will receive consideration for employment without regard to age, race, color, creed, religion, sex, sexual orientation, gender identity or expression, pregnancy, breastfeeding, genetic information, refusal to submit to a genetic test or make available to an employer the results of a genetic test, atypical hereditary cellular or blood trait, national origin, nationality, ancestry, disability, marital status, liability for military service, or status as a protected veteran.

Our Network

Hackensack Meridian Health (HMH) is a Mandatory Influenza Vaccination Facility

As a courtesy to assist you in your job search, we would like to send your resume to other areas of our Hackensack Meridian Health network who may have current openings that fit your skills and experience.