Responsible for safe and effective transitioning of patients from acute or inpatient care setting, to the home in a cost efficient manner. The overall goal of this position is to improve patient outcomes and prevent hospital readmissions for high risk patients. Collaboration and education with other team members and health care providers in an effective manner is an essential aspect of this position. Demonstrates cost savings of this program.
- Active NJ Licensed Nurse Practitioner
- 2 + years’ experience
Duties and Responsibilities
- Identifies, assesses and manages patients during care transitions per established criteria.
- Assists in identifying best practices, which prevent hospital readmissions and improves the overall outcomes for high risk patients.
- Coordinates transition of care between inpatient and other settings with the practitioner, Home Care staff, community based agencies, social workers, hospital/nursing facility discharge planner, and/or other providers as required.
- Utilizes effective communication and education strategies to assist patients in self-management
- Demonstrates excellent interpersonal and communication techniques with other health care providers.
- Coordinates necessary services with participating ancillary service providers and public agencies as appropriate to ensure quality, cost effective care and reduced readmissions for the member.
- Documents medical management within the electronic medical record system. Documentation includes assessments, care plans and updates, contacts and planned interventions, patient/family responses and evaluation of the effectiveness of the plan of care
- Documents a cost analysis of services. Contributes to monthly departmental Cost Savings Report and decreased readmission rates for the populations served.
- Attends meetings related to care coordination and transitional care.
- Performs mentorship, assisting leadership in coordination of work, quality review, etc.
- Involved in program development and process improvement activities for the department.
- Other Duties as assigned.
KNOWLEDGE, SKILLS AND ABILITIES
- Exceeds customer’s expectations
- Demonstrated adaptability and flexibility to changes and response to new ideas and approaches.
- Demonstrates professionalism at all times.
- Computer and Microsoft Office experience