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.
The Transitional Nurse Navigator, Pulmonary (TNNP), in collaboration with the medical care team, advanced practice providers, and the entire healthcare team, oversees and supports the pulmonary patient and their significant other(s). The TNNP is a member of the healthcare team and is responsible for coordinating, communicating and facilitating the care of selected patients with primary pulmonary care needs. The TNNP is accountable for a designated case load determined by the careful daily selection of eligible patients. They assess, plan, and facilitate, with patients/families and healthcare professionals involved in the patient's care to meet treatment goals, and arrange for the appropriate next steps. Promotes safe and timely transition of patients from varying levels of care in the hospital and community.
Responsibilities
A day in the life of a Transitional Nurse Navigator at Hackensack Meridian Health includes:
- Participates 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.
- Screening: All patients who are admitted for medical care will be screened for potential eligibility to the pulmonary transitions of care program. All eligible patients will be enrolled.
- Patient/Family interview: Meets directly with the patient/family to assess needs, based on assessment and prior evaluation from care coordinators/case management and develop an individualized needs assessment.
- Person-centered transitional care plan (TOC) development: Develops a TOC plan, in collaboration with the patient/family, patient caregiver, patient support persons and healthcare team that will provide maximum benefit for each patient. Reassesses periodically and evaluates against care goals and the plan of care and, when indicated, the plan or goals are revised. Completes all other necessary duties with attention to detail and in a timely manner.
- Educator: Provides appropriate patient and family education regarding diagnosis, treatment, and self-care management and documents outcomes in the medical record.
- Bidirectional communicator: Facilitates communication and coordination between members of the health care team and involves the patient/family in the decision making process, in order to minimize fragmentation of services, manage resources and remove barriers to the discharge plan of care.
- Safe transition and quality assurance: In addition to aligning with patient quality metrics, confirms the patient has a primary care provider, pulmonary providers upon discharge and refers appropriately to a primary care provider and/or pulmonologist if needed. Works collaboratively with all members of the multidisciplinary health care team and community partners for timely and appropriate transitions to the next appropriate level of care, including transition to the TOC unit. Ensures timely follow up appointments with appropriate care providers, post discharge.
- Networking and resources: Maintains current and up to date information of community resources and refers patients to those community resources which will enhance patient's life and clinical outcomes. Consults with other community agencies and committees to identify potential resources to support patients and their families. Provides patients and families with community resources and discharge care coordination options. Will actively work to find community partners across the care continuum.
- Documentation: Documents patient/family encounters, interventions provided, and communication delivered in the electronic health record. The Electronic Health Record will reflect the needs of the patient, any education needed based on the patient's medical history, coordination of follow-up care, and referral to community services. Medical records reflect that each patient's discharge plan is re-assessed in response to changes in patient's needs and Social Determinants of Health.
- Quality assurance and program development: Participates actively on appropriate workgroups, and/or meetings. Is a positive problem solver. Identifies and refers quality issues for review to the pulmonary/medical and transition of care team locally. Monitor readmission rates for Medicare and all payers, and implement needed performance improvement projects to improve scores in collaboration with the pulmonary/medical team.
- Other duties and/or projects as assigned.
- Adheres to HMH Organizational competencies and standards of behavior.
Qualifications
Education, Knowledge, Skills and Abilities Required:
- 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 judgements 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.
Education, Knowledge, Skills and Abilities Preferred:
- 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.
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 area of specialty (pulmonary/chronic disease management)
- Certification in care coordination and/or transitional care
- Project management certification
If you feel that the above description speaks directly to your strengths and capabilities, then please apply today!
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