Post Acute Care Coordinator - Somerset, NJReq #:0000161439

Category:Nursing

Status:Full-Time

Shift:Day

Facility:RWJBarnabas Health Corporate Services

Department:Accountable Care Organization

Location:

RWJ - 379 Campus Dr. Somerset, 379 CAMPUS DRIVE, SOMERSET, NJ 08873

Job Overview:

As part of RWJ Barbanas Health Corporate Population Health team team you will play an instrumental role in a department that is providing fully coordinated patient care from a holistic approach to improve the overall care of patients who are part of the value-based, ACO, and bundled payment programs across the healthcare continuum by ensuring the population receives the right care, at the right time, by the right team. As a member of the patient s multidisciplinary team in the Post Acute setting, the Post-Acute Care Coordinator - RN evaluates the treatment plan and goals of care at the Post-Acute Care facility. The Post-Acute Care Coordinator partners with the clinical team at the Post-Acute care facilities to ensure patients are progressing towards discharge goals as well as coordinating next site of care discharge planning and ensure timely follow up with providers and service in the community. The Post-Acute Care Coordinator also works with other Population Health programs to assist patients in transitioning to the next site of care.

Qualifications:

Required:

• Associates s Degree in Nursing from accredited school

• 3-5 years experience in Nursing with managing relationships between acute and post-acute facilities

• A personal commitment to a person-centered approach, along with strong relationship building, communication, and active listening skills

• Must have the ability to travel to post-acute sites and hospital sites.

• Must have strong organizational skills, with an ability to prioritize multiple tasks and deadlines

• Strong leadership skills to achieve buy-in and collaboration toward objectives

Certifications and Licenses Required:

• NJ Licensed Practical Nurse or NJ Registered Nurse

Scheduling Requirements:

• Travel is required to Hudson, Essex, and Union counties. As well as Subacute Nursing Facilities and RWJ hospital sites.

Essential Functions:

• Performs initial and on-going assessments of patient's condition during and after a post acute episode.

• Establishes, revises and evaluates a plan of care which is appropriate to problems identified and involves the patient/family.

• Participates in multidisciplinary rounds with the clinical team in the Post Acute setting to create a collaborative care plan for patients that is patient and family centered, follows evidence based clinical guidelines and promotes the best outcome for the patient.

• Provides for continuity of care by participating in discharge planning with patients, families and other health care providers as appropriate, providing home instructions to patients and caregivers, recommending and or providing equipment/ home modifications, and recommending appropriate follow-up care if needed.

• Provides education to patient/family/staff by assessing patient/family educational needs.

• Maintains appropriate documentation that details the patient's response to therapy and the need for skilled intervention as outlined by regulatory bodies.

• Serves as a resource for the Post Acute facilities in finding and scheduling follow up providers, specialists, and services across the RWJ Barnabas medical neighborhood.

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Additional Information:

At RWJBarnabas Health, our market-competitive Total Rewards package provides comprehensive benefits and resources to support our employees physical, emotional, social, and financial health.

• Paid Time Off (PTO)

• Medical and Prescription Drug Insurance

• Dental and Vision Insurance

• Retirement Plans

• Short & Long Term Disability

• Life & Accidental Death Insurance

• Tuition Reimbursement

• Health Care/Dependent Care Flexible Spending Accounts

• Wellness Programs

• Voluntary Benefits (e.g., Pet Insurance)

• Discounts Through our Partners such as NJ Devils, NJ PAC, Verizon, and more!

Choosing RWJBarnabas Health!

RWJBarnabas Health is the premier health care destination providing patient-centered,

high-quality academic medicine in a compassionate and equitable manner, while delivering

a best-in-class work experience to every member of the team. We honor and appreciate the privilege of creating and sustaining healthier communities, one person and one community at a time. As the leading academic health system in New Jersey, we advance innovative strategies in high-quality patient care, education, and research to address both the clinical and social determinants of health.

RWJBarnabas Health aims to truly make a unique impact in local communities throughout New Jersey. From vastly improving the health of local residents to creating educational and career opportunities, this combination greatly benefits the state. We understand the growing and evolving needs of residents in New Jersey whether that be enhancing the coordination for treating complex health conditions or improving community health through local programs and education.

RWJBarnabas Health is an Equal Opportunity Employer