Pulmonary Care Nurse Coordinator

2 weeks ago

Edison, New Jersey, United States Hackensack Meridian Health Full time
Overview

At Hackensack Meridian Health, our team members are essential to our mission of enhancing patient care and fostering a supportive work environment.

We are dedicated to helping our patients lead healthier lives while ensuring our employees thrive in their roles.

Our culture emphasizes collaboration and connection, where competitive benefits are just the starting point. We are committed to uplifting one another and serving our community.

Together, we strive for continuous improvement, advancing our mission to revolutionize healthcare and be a beacon of positive change.

Role Summary:
The Transitional Nurse Navigator for Pulmonary Care (TNNP) collaborates closely with the medical team, advanced practice providers, and the entire healthcare staff to oversee and support pulmonary patients and their significant others.

The TNNP is an integral part of the healthcare team, responsible for coordinating, communicating, and facilitating care for patients with primary pulmonary needs.

This role entails managing a designated caseload, carefully selecting eligible patients daily.

The TNNP assesses, plans, and facilitates care in partnership with patients, families, and healthcare professionals to achieve treatment objectives and arrange appropriate next steps, ensuring safe and timely transitions for patients across various care levels.

Key Responsibilities:

A typical day for a Transitional Nurse Navigator at Hackensack Meridian Health includes:

  • Collaboration: Engage with physicians, nursing staff, and interdisciplinary teams to assess, plan, implement, and evaluate care for selected patients and their families.
  • Screening: Conduct screenings for all patients admitted for medical care to determine eligibility for the pulmonary transitions of care program, enrolling all eligible patients.
  • Patient/Family Engagement: Meet directly with patients and families to assess needs, utilizing prior evaluations from care coordinators to develop individualized needs assessments.
  • Transitional Care Plan Development: Collaborate with patients, families, caregivers, and the healthcare team to create a person-centered transitional care plan, reassessing and adjusting as necessary.
  • Education: Provide comprehensive education to patients and families regarding diagnoses, treatments, and self-care management, documenting outcomes appropriately.
  • Communication: Facilitate effective communication among healthcare team members and involve patients and families in decision-making to minimize service fragmentation.
  • Quality Assurance: Ensure alignment with patient quality metrics, confirming primary care and pulmonary provider appointments upon discharge, and referring as needed.
  • Resource Networking: Maintain updated knowledge of community resources, referring patients to enhance their clinical outcomes and quality of life.
  • Documentation: Accurately document patient encounters, interventions, and communications in the electronic health record, reflecting patient needs and care coordination.
  • Quality Improvement: Actively participate in workgroups and meetings, identifying quality issues for review and monitoring readmission rates to implement performance improvement projects.

Adhere to organizational competencies and standards of behavior.


Qualifications:

Required:
Bachelor's degree in nursing from an accredited program.
Minimum of 2 years of experience as a registered nurse, particularly with pulmonary patients or chronic disease management.
Strong organizational and problem-solving skills, along with excellent critical thinking abilities.

Preferred:
Master's degree in nursing or a related field.
2 or more years of experience in leadership, education, case management, or social work.
Project management skills.

Licenses and Certifications Required:
NJ State Professional Registered Nurse License.
AHA Basic Health Care Life Support HCP Certification.
Advanced Cardiac Life Support Certification.

Licenses and Certifications Preferred:
Certification in specialty areas such as pulmonary or chronic disease management.
Certification in care coordination and/or transitional care.
Project management certification.

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