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Pulmonary Care Nurse Coordinator
2 months ago
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 achieve healthier lives while also ensuring that our employees thrive within a culture of collaboration and connection.
The Transitional Nurse Navigator for Pulmonary Care (TNNP) collaborates closely with the medical team, advanced practice providers, and other healthcare professionals to oversee and support patients with pulmonary conditions and their families.
The TNNP plays a crucial role in coordinating, communicating, and facilitating care for patients with primary pulmonary needs, managing a designated caseload based on the careful selection of eligible patients.
This role involves assessing, planning, and facilitating care in partnership with patients, families, and healthcare professionals to achieve treatment objectives and organize appropriate next steps.Key Responsibilities
A typical day for a Transitional Nurse Navigator at Hackensack Meridian Health includes:
Engaging in collaboration with physicians, nursing staff, and interdisciplinary teams to assess, plan, implement, and evaluate care for selected patients and their families.
Screening:
All patients admitted for medical care will undergo screening for potential eligibility in the pulmonary transitions of care program, with all eligible patients being enrolled.
Patient/Family Assessment:
Conducting direct meetings with patients and families to evaluate needs, utilizing prior assessments from care coordinators and case management to develop a tailored needs assessment.
Transitional Care Plan Development: Collaborating with patients, families, caregivers, and the healthcare team to create a personalized transitional care plan that maximizes benefits for each patient. Periodic reassessments will be conducted to evaluate progress against care goals, with adjustments made as necessary.
Completing all required tasks with meticulous attention to detail and timeliness.
Education:
Delivering appropriate education to patients and families regarding diagnoses, treatment options, and self-management strategies, while documenting outcomes in the medical record.
Communication:
Facilitating effective communication and coordination among healthcare team members, involving patients and families in decision-making to minimize service fragmentation and manage resources effectively.
Quality Assurance:
Ensuring alignment with patient quality metrics, confirming that patients have primary care and pulmonary providers upon discharge, and making appropriate referrals as needed.
Collaborating with multidisciplinary healthcare teams and community partners to ensure timely transitions to the next level of care, including follow-up appointments post-discharge.
Resource Networking:
Maintaining current knowledge of community resources and referring patients to those that will enhance their quality of life and clinical outcomes. Engaging with community agencies to identify additional support for patients and families.
Documentation:
Accurately documenting patient and family interactions, interventions, and communications in the electronic health record, ensuring that records reflect patient needs, education provided, and follow-up care coordination.
Medical records will demonstrate that discharge plans are reassessed in response to changes in patient needs and social determinants of health.
Quality Improvement:
Actively participating in relevant workgroups and meetings, identifying quality issues for review, and monitoring readmission rates to implement performance improvement initiatives in collaboration with the healthcare team. Other duties and projects may be assigned as needed.
Adhering to organizational competencies and standards of behavior is essential.
Qualifications
Required Education, Knowledge, Skills, and Abilities:
Bachelor's degree in nursing from an NLN/AACN accredited program.
A minimum of 2 years of experience as a registered nurse, particularly in the care of pulmonary patients or chronic disease management.
Excellent critical thinking abilities.
Ability to thrive in a fast-paced team environment.
Capability to prioritize and manage multiple tasks effectively.
Sound clinical judgment and professionalism under pressure.
Demonstrated cultural competency and customer service skills, along with health literacy.
Strong written and verbal communication skills.
Proficient in computer applications, including Microsoft Office and Google Suite.
Preferred Education, Knowledge, Skills, and Abilities:
Master's degree in nursing or a related field.
At least 2 years of experience in leadership, education, case management, or social work.
Licenses and Certifications Required:
New Jersey State Professional Registered Nurse License.
AHA Basic Health Care Life Support HCP Certification.
Advanced Cardiac Life Support Certification.
Licenses and Certifications Preferred:
Certification in a specialty area (pulmonary/chronic disease management).
Certification in care coordination and/or transitional care.
Project management certification.
