Pulmonary Nurse Navigator
1 month ago
At Hackensack Meridian Health, we are committed to providing exceptional patient care and improving the health of our community. We are seeking a highly skilled and compassionate Transitional Nurse Navigator to join our team.
Job Summary:The Transitional Nurse Navigator will play a critical role in coordinating and facilitating the care of patients with primary pulmonary care needs. This individual will work collaboratively with the medical care team, advanced practice providers, and the entire healthcare team to ensure seamless transitions of care and optimal patient outcomes.
Responsibilities:- Participate in the collaboration with physicians, nursing staff, and interdisciplinary team in the assessment, planning, implementation, and evaluation of care for selected patients and their families.
- Screen all patients who are admitted for medical care for potential eligibility to the pulmonary transitions of care program.
- Meet directly with the patient/family to assess needs and develop an individualized needs assessment.
- Develop a person-centered transitional care plan (TOC) in collaboration with the patient/family, patient caregiver, patient support persons, and healthcare team.
- Reassess periodically and evaluate against care goals and the plan of care, revising when indicated.
- Provide patient and family education regarding diagnosis, treatment, and self-care management and document outcomes in the medical record.
- Facilitate communication and coordination between members of the healthcare team and involve the patient/family in the decision-making process.
- Confirm the patient has a primary care provider and pulmonary providers upon discharge and refer appropriately to a primary care provider and/or pulmonologist if needed.
- Maintain current and up-to-date information of community resources and refer patients to those resources that will enhance patient life and clinical outcomes.
- Bachelor's degree in nursing field, graduated from an NLN/AACN accredited program in nursing.
- Minimum of 2 years experience as a registered nurse, with care of pulmonary patients or chronic/acute on chronic disease management.
- Strong organization and problem-solving skills.
- Excellent critical thinking skills.
- Ability to work in a fast-paced team environment.
- Ability to prioritize and multitask.
- Ability to make sound, independent clinical judgments and act professionally under pressure.
- Demonstrate ability to provide age-appropriate skills, cultural competency, and customer service skills and health literacy.
- Excellent written and verbal communication skills.
- Proficient computer skills that include but are not limited to Microsoft Office and/or Google Suite platforms.
- Master's degree in nursing or related field.
- Minimum of 2 or more years of experience as a registered nurse in leadership, education, case/care management, or social work.
- Project management skills.
- NJ State Professional Registered Nurse License.
- AHA Basic Health Care Life Support HCP Certification.
- Advanced Cardiac Life Support Certification.
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