Nurse Navigator, Transition of Care-Central Region

Hackensack Meridian Health•Iselin, NJ

8d•$113,610

About The Position

The Transitions of Care Nurse Navigator is a member of the healthcare team who coordinates, communicates, and facilitates care for patients with medical, behavioral, and maternal health needs. The navigator manages a designated caseload by selecting eligible patients daily, assessing needs, planning care with patients and families and healthcare professionals, supporting treatment goals, and arranging appropriate next steps. The role oversees interfacility coordination and handoffs between acute and outpatient services. The position is based at Carrier Clinic in Belle Mead, New Jersey.

Requirements

Bachelor’s degree in nursing (BSN), or one year of experience for non-BSN HackensackUMC employees.
Knowledge of managed care principles.
Knowledge of the New Jersey Quality Improvement Program and its quality metrics.
Knowledge of healthcare delivery systems, utilization review, and case review procedures.
Knowledge of Social Determinants of Health.
Working knowledge of benefit plans, including Medicaid HMOs.
Computer skills, including Google Docs and data entry.
Ability to delegate effectively to a Transitions Assistant.
Strong organizational and problem-solving skills.
Excellent oral and written communication and interpersonal skills.
Ability to communicate and collaborate effectively with physicians, patients, families, and ancillary staff.
Excellent critical-thinking skills.
Ability to work in a fast-paced team environment, prioritize, and multitask.
Ability to make sound independent clinical judgments and act professionally under pressure.
Ability to provide age-appropriate patient education and communication, with cultural competency, customer service, and health literacy skills.
New Jersey State Professional Registered Nurse License.
AHA Basic Health Care Life Support HCP Certification.

Nice To Haves

Three to five years of clinical experience.
Experience with relevant systems, including Google Docs and EPIC.
Certified Case Manager or Accredited Case Manager Certification.

Responsibilities

Screen patients admitted for medical care for potential eligibility for the Transitions of Care program and enroll eligible patients.
Meet with patients and families to assess needs and develop an individualized needs assessment in collaboration with the Transitions Assistant.
Coordinate communication among healthcare team members and involve patients and families in decisions to reduce fragmentation, manage resources, and address barriers to discharge plans.
Develop a Transitions of Care plan with patients, families, caregivers, support persons, and the healthcare team, aligned with patient quality metrics.
Confirm patients have an appropriate primary care, OB-Gyn, or behavioral health provider upon discharge and make referrals as appropriate, including to an FQHC or provider that accepts the patient’s insurance.
Participate in multidisciplinary team rounds for the assigned unit and raise discharge and readmission-risk concerns for discussion and resolution.
Collaborate with the multidisciplinary healthcare team and community partners to support timely transitions to the appropriate next level of care.
Maintain current knowledge of community resources, refer patients to relevant resources, consult community agencies and committees, and identify potential community partners.
Document and communicate patient needs, education, follow-up coordination, and referrals in the Electronic Health Record and with the multidisciplinary team.
Provide patients and families with community resources and discharge care coordination options.
Participate in appropriate workgroups and meetings, identify quality issues, and refer them to the Regional Manager for review.
Periodically reassess patients against care goals and revise plans when needs or Social Determinants of Health change.
Collaborate with social work and outside agencies on crisis intervention, counseling support and referrals, abuse or neglect concerns, psychosocial assessment, and referrals to ICMS or PACT Programs as needed.
Collaborate with Utilization Review Nurses.
Complete other necessary duties accurately and promptly.
Coordinate or refer patients to services and programs including primary care physicians, behavioral health providers, HUMG Internal Medicine Clinic, Human Dimensions Program, Meds to Bed, Lyft Concierge Transportation, Financial Assistance Office, HMH Quit Center, North Hudson Clinics, Medication Assistance Programs, and NowPow.