An Advanced Practiced Nurse (preferably hold national certification in area of applicable expertise) with strong clinical and critical thinking skills, as well as excellent communication skills. The Transitional Care Coordinator will be knowledgeable in chronic disease management. He or she must be a true team player capable of and willing to support each team member in overall goal achievement of customer satisfaction and positive resident / patient outcomes. Goals: The Nurse Practitioner will be a driving force to ensure patient transitions are as smooth and as safe a process as possible, thus driving positive clinical outcomes, patient, family and physician satisfaction and preventing avoidable readmissions to hospitals. Patients identified, as high risk for hospital readmission will be a priority focus. The Transitional Care Coordinator will build key hospital and community relationships and will provide clinical guidance to support unit based care mangers and staff nurses.
Enter Essential Functions
Admissions: Evaluation of each new admission for diagnosis, medications, and medical plan of care to ensure completeness, appropriateness and to clarify any issues.
BCLS Certification: Successful completion of Basic Cardiac Life Support and maintains current certification through the American Heart Association. Maintains current certification.
Business Relationships: Develop ongoing positive, collaborative relationships with key customers: physicians, hospital leaders, care managers, social workers, home care etc.
Care Plan: High risk patient’s clinical progress will be tracked daily to ensure care planning and physician’s orders are implemented.
Clinical & Regulatory Practice Requirements: Clinical practice accurately reflects NJ Board of Nursing regulations, ANA Code of Ethics, the current NJ Department of Health requirements, and institutional policies and procedures. Practices within all NJ Board of Nursing regulations and procedures Establish effect communication directly with Physician on site and at least biannually with the Medical Director.
Clinical Competence: Performs comprehensive initial assessment, history, physical exam and ongoing assessments. Consistently able to demonstrate clinical competence in the assessment of work related injury patients, health screening for employees with a variety of occupational demands, immunization services, including hepatitis B, Tuberculosis screening, etc. Maintains licensure with the New Jersey Board on Nursing as an Advanced Practice. Prepares all documentation requirements to remain in good standing for licensure and regulations for medical staff membership.
Continuing Education: Independently participates in continuing education and maintains documentation. Develops a personal plan of development in area of clinical expertise, conferring with Medical Director on goals and objectivesActively seeks out opportunities for self-development on an annual basis. Seeks approval in a timely manner to attend programs to achieve educational goals.
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