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Transition Assistant

4 months ago

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Overview

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.

As a part of the population health team, the Transition Assistant - Licensed Practical Nurse is responsible for assigned patient care and related administrative duties under the direct supervision of a licensed healthcare practitioner. Responsibilities for this role include: patient education and outreach, follow-up phone calls for disease management, managing patients at risk for readmissions, assisting in quality audits, and other duties as assigned.

Responsibilities

A day in the life of a Transition Assistant - Licensed Practical Nurse at Hackensack Meridian Health includes:

  • Works in collaboration with the community-based care manager to support and coach patients through identifying or recommending in network, community based assistance, or support programs to help meet patient goals.
  • Participates in making follow-up phone calls to the target population as directed.
  • Monitor that appropriate home care, hospice care and other ancillary services (DME, infusion services etc.) are in place and are being delivered as directed by the care team for low and rising risk patients post discharge.
  • Where applicable - Coach and communicate with patients to ensure they are aware of discharge instructions, have necessary prescriptions and access to medications.
  • Reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse.
  • Embedment or Travel to various office settings (i.e. physician practice, acute/post-acute settings) to: educate physicians and staff on payer programs and perform chart reviews.
  • Works on multiple projects concurrently in a fast paced, timeline driven environment.
  • Identifies patient complaints or issues that must be reported to the appropriate person (i.e. clinician, social worker, care manager, or supervisor).
  • Engages in patient advocacy, empowers patients to take charge or leadership in their healthcare, and coaches patients to ask questions to understand their disease process as well as their care plan.
  • Conducts follow-up telephone calls to identified patients to ensure safe patient transitions from a hospital setting to home.
  • Forge long term relationships with assigned practices.
  • Acts as a liaison between patients, primary care office and community partners.
  • Provide reports to practices that will assist with quality metric performance and to maximize shared savings opportunities for designated programs.
  • Performs technical, administrative, and clerical duties as directed by the licensed healthcare practitioner and within the scope of training and certification.
  • Documents data and care in the population health care management system and maintains confidentiality.
  • As a part of the Care Management Team work to utilize software to produce and report on outcome measures for ER, Inpatient and Sub-acute usage.
  • Compliant with Recognized Standards or Guidelines for practice, Service Specific Policies & Regulatory Agencies/Standards governing departmental services/operations.
  • Uses pertinent performance metrics to drive improvement in practice that will enhance patient or consumer safety, satisfaction, efficient and effective care.
  • Focus efforts on reducing emergency department (ED) visits as a way to reduce costs and improve quality of care.
  • Visit assigned practices quarterly at a minimum to review cases and discuss pertinent findings relating to patient education, follow up care and utilization.
  • Identify and promote best practices.
  • Identifies and participates in the development of strategies to reduce unnecessary utilization and readmission resource consumption.
  • Conducts follow-up calls and forward resources to patient's based on established physician care plan.
  • Maintain statistics on activity as required by department and Federal programs.
  • Perform Chart Review of clinical records for gaps in quality care metrics and to ensure documentation conforms to industry standards.
  • Create corrective plans to facilitate collection and reporting of required quality metrics.
  • Assist in workflow design that will facilitate collection and compliance with industry evidenced based standards and clinical quality metrics.
  • Interprets provided data for custom tailored interventions to the assigned patients population.
  • Other duties and/or projects as assigned.
  • Adheres to HMH Organizational competencies and standards of behavior.

Qualifications

Education, Knowledge, Skills and Abilities Required:

  • One to three years of patient care experience.
  • Excellent written and verbal communication skills.
  • Proficient computer skills that may include but are not limited to Microsoft Office and/or Google Suite platforms.

Education, Knowledge, Skills and Abilities Preferred:

  • Primary care & experience working with seniors strongly preferred.
  • Knowledge about population health management and clinical integration principles and processes a plus.
  • Exceptional communication skills to enable communication and collaboration with physician, patients, families, and ancillary staff.
  • Ability to work cooperatively with peers and supervisors.
  • Excellent critical thinking skills.
  • Ability to work in a fast pace team environment.
  • Ability to prioritize and multitask.

Licenses and Certifications Required:

  • Licensed Practical Nurse.
  • Valid Driver's License.

If you feel that the above description speaks directly to your strengths and capabilities, then please apply today    

Our Network

Hackensack Meridian Health (HMH) is a Mandatory Influenza Vaccination Facility

As a courtesy to assist you in your job search, we would like to send your resume to other areas of our Hackensack Meridian Health network who may have current openings that fit your skills and experience.