Ambulatory Nurse Navigator, Transitions of Care Navigator (TOC)

Hackensack Meridian Health•Tinton Falls, NJ

10d

About The Position

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.

Requirements

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

Nice To Haves

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

Responsibilities

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.