Part-Time RN Care Transition Coach

Job Summary:
Responsible for safe and effective transitioning of patients from acute or inpatient care setting, to the home in a cost efficient manner. The overall goal of this position is to improve patient outcomes and prevent hospital readmissions for high risk patients. Collaboration and education with other team members and health care providers in an effective manner is an essential aspect of this position.

Required Qualifications:

  • Active NJ Licensed Registered Nurse
  • BSN and MS
  • 2 + years’ experience

Essential Functions

Duties and Responsibilities

  • Identifies, assesses and manages patients during care transitions per established criteria
    Assists in identifying best practices which prevent hospital readmissions and improve the overall outcomes for high risk patients
  • Coordinates transition of care between inpatient and other settings with the practitioner, home care staff, community-based agencies, social workers, hospital/nursing facility discharge planners, and/or other providers as required
  • Utilizes effective communication and education strategies to assist patients in self-management
  • Coordinates necessary services with participating ancillary service providers and public agencies as appropriate to ensure quality, cost effective care and reduced readmissions for the patient
  • Documents a cost analysis of services and contributes to monthly departmental Cost Savings Report and decreased readmission rates for the populations served
  • Attends meetings related to care coordination and transitional care
  • Performs mentorship by assisting leadership in coordination of areas including work, quality review, etc.
  • Performs Quality Assessment Performance Improvement activities to assist leadership in identifying areas for improvement
  • Other Duties as assigned

Knowledge, Skills and Abilities

  • Demonstrates excellent interpersonal and communication techniques with other health care providers
  • Demonstrates adaptability and flexibility to changes and response to new ideas and approaches
  • Demonstrates professionalism at all times
  • Computer literate with Microsoft Office proficiency