Nurse Navigator, Transitions Of Care

Nurse Navigator, Transitions of Care

HMH HOSPITALS CORPORATION Edison, New Jersey

Requisition #
• Shift: Day
• Status:
Full Time with Benefits

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.

• All patients who are admitted for medical care will be screened for potential eligibility to the Transitions of Care (TOC) program. All eligible patients will be enrolled.
• Meets directly with patient/family to assess needs and develop an individualized needs assessment to plan in collaboration with the Transitions Assistant.
• Facilitates communication and coordination between members of the health care team and involves the patient/family 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 TOC plan, in collaboration with the patient/family, patient caregiver, patient support persons and healthcare team that will provide maximum benefit for each patient. In addition to aligning with patient quality metrics. Confirms the patient has a primary care provider, OB‑Gyne, or Behavioral Health providers upon discharge and refers appropriately to an FQHC or Provider that accepts patients’ medical insurance.
• Participates in Multidisciplinary Team Rounds, specific to the assigned unit. Brings forth issues which impact patient‑s discharge as well as the risk of readmission to the team, for discussion and resolution with patient’s health care team and Transitions Assistant.
• Works collaboratively with all members of the multidisciplinary health care team and community partners for timely and appropriate transitions to the next 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 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 referral to complex Behavioral Care services.
• Provides patients and families with community resources and discharge care coordination options.
• Participates actively on appropriate work groups, and/or meetings. Is a positive problem solver. Identifies and refers quality issues for review to the Regional 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 discharge plan is re‑assessed in response to changes in patient’s needs and Social Determinants of Health.
• Collaborates with social work and outside agencies to support the following functions; crisis intervention, counseling support and referrals, abuse/neglect, psychosocial assessment and referrals to ICMS or PACT Programs as needed.
• Completes all other necessary duties with attention to detail and in a timely manner.
• Collaborates with Utilization Review Nurses.
• Referrals: a) Primary Care Physicians b) Behavioral Health Providers c) HUMG Internal Medicine Clinic d) Human Dimensions Program e) Meds to Bed program f) Lyft Concierge Transportation g) Financial Assistance Office h) HMH Quit Center i) North Hudson Clinics j) Medication Assistance Programs k) Now Pow

• Bachelor’s degree in nursing (BSN) or one year experience for non‑BSN Hackensack UMC…