RN, Care Transitions Coordinator; onsite) Evenings

Location:

Teaneck, NJ, United States
Date Posted:
Feb 21, 2025

Welcome to Holy Name
, a medical center where innovation is not just a goal — it's a commitment. Here, medical excellence thrives, allowing hope to reign supreme and leaving no room for fear. At our hospital, every patient is cared for with undivided attention — because healing every soul is our sole focus.

Holy Name is New Jersey's only independent Catholic health system, comprising a 361-bed acute care hospital, a renowned cancer center, a state-of-the-art fitness center, a residential hospice, a prestigious nursing school, and an extensive physician network. Healing at Holy Name goes beyond medicine and technology – it is infused with faith, conviction, compassion, and a commitment to educating the next generation of healthcare professionals through graduate medical education, a Pharmacy Residency Program, and our Institute for Simulation Learning.

Our mission to provide care for the body, mind, and soul spans education, prevention, diagnosis, treatment, rehabilitation, and overall wellness. This is at the core of who we are and what we do, and we've done it this way across generations, every single day, for nearly 100 years. Every innovation, medical breakthrough, and groundbreaking treatment is powered by some of the best minds in medicine, ensuring nothing is left on the table or the road to recovery.

A Brief Overview
The Care Transitions Coordinator is responsible for facilitating and coordinating services for patients through the continuum of care. The Care Transitions Coordinator ensures appropriate utilization of resources and safe delivery of care to all patients and provides quality and cost-effective care that will lower Length of Stay (LOS) and decrease the fragmentation of services that can potentially compromise patient care. Care Transitions Coordinator collaborates efforts as a team in order to perform one or more of the following roles:
Discharge Planning and Disease Management of acute and chronic conditions, facility placement needs as needed and timely referrals and evaluations of all post-acute care needs. The Care Transitions Coordinator plays a pivotal role for patients as part of the interdisciplinary team in order to ensure patient safety, quality of care and positive patient outcomes. Rotation of coverage for weekends and holidays will be required and are assigned throughout the year.

What you will do

• Modification of plan of care, as necessary, to meet the ongoing needs of the patient.
• Communicate relevant information to third party payors and the care team.
• Completion of all required documentation in patient records.
• Issues Notices of Non-Coverage per hospital policy.
• Refers appropriate cases for social work intervention based on department criteria.
• Verifies patient demographics and insurance information is correct.
• Expedites execution of plan of care for patients in Observation units.
• Arranges transportation for patients slated for discharge.
• Uphold compliance of regulatory standards for Observation patients including CMS requirement for Code 44.
• Utilizes “Patient Choice” list for support services post discharge and documents.
• Initiates home care referrals for VNS, orders durable medical equipment and arranges ambulance transportation as needed for patients prior to discharge or transfer to another facility.
• Participates as an active, informative and cooperative team member of the health care staff by attending discharge rounds for case finding/follow up and participating in the discharge plan while acting as an advocate for the patient. Arranges family meetings to assist in discharge planning as indicated.
• Other duties as assigned.

Education…