Transition Care Coordinator

MAIN FUNCTIONS: Provide Transition care services to patients discharged home, home with services, or to a skilled-nursing facility. Readmission Reduction Program Conduct home visits to patients discharged from a CarePoint Health acute-care facility as per policy and protocol. Maintain home visit productivity of at least 20 home visits per week. Coordinates with the interdisciplinary team to develop an individualized plan of care. Ensures accuracy of the medication reconciliation at the time of discharge. Patients receive home visits according to the Transition in Care Home Visit policy & protocol. Assist with the completion and submission of the B-CARE tool for the Bundled Payment initiative. Takes patient histories, conducts comprehensive physical examinations; write progress notes; obtain psychosocial history relevant to patient care; identify and provides consultations required under the guidance of the physician. Assess the needs of patients, families, and communities including assessment of the patient’s home and working environment. Monitors, records, and reports symptoms and changes in patient’s health status Documents assessment, findings, and interventions initiated. Coordinates with healthcare team members to provide outpatient follow-up. Initiates referrals to the RRP social worker, specialty services and fosters continuity of care. Performs minor tests in the home including phlebotomy, obtaining culture samples, fingerstick prothrombin and international ratio, blood glucose testing in the patients’ homes. Provides health care, first aid, pharmacological and non-pharmacological intervention including nebulizer treatments, stat oral medications, under the direction of the Physician. Provides teaching and counseling in the areas of health promotion, disease prevention, maintenance, and management of acute/chronic diseases. Modify treatment plans in response to the patient’s status. Confirms accuracy of the medication reconciliation under the physician’s guidance. EDUCATION: Graduate of an accredited school of nursing, with an Associates or Bachelors in Nursing. EXPERIENCE: Full time experience as a Registered Nurse with ICU and/or ER experience; Home care experience preferred. . LICENSURE / QUALIFICATIONS: Current NJ Licensure as a Registered Nurse in specialty areas as required. SHIFT: Monday through Friday 8am to 4:30pm. Weekend coverage possible. On-call coverage possible. We are an Equal Opportunity Employer and a member of the Employer Partnership of the Armed Forces. CarePoint Health Plans Coordinated Healthcare: That's the Point! www.CarePoint.org CarePoint Health has combined the resources of three hospitals— Bayonne Medical Center, Christ Hospital, and Hoboken University Medical Center—and the medical practices of over 300 leading doctors in the Northern New Jersey Area. We also have insurance and research divisions of our healthcare system. CarePoint Health Plans, headquartered in Jersey City, provides Medicare Advantage programs that serve residents of the Hudson County area, and Care Point Health Research Institute, with locations at each of our three hospitals, has partnered with major pharmaceutical corporations to conduct research to develop treatments for cancer.