Nurse Navigator - Mountainside/Hackensack

Full Time/Day Shift

Who We Are

Patient focused, community oriented, conveniently located and equipped with technology that rivals the nation's most prestigious healthcare systems, Hackensack Meridian Health Mountainside Medical Center offers a comprehensive and growing array of services delivered by caring and highly skilled medical professionals. We're proud of the therapeutic and administrative upgrades we have made. Mountainside Medical Center has been serving Montclair and its surrounding New Jersey communities since 1891. The physicians, nurses and volunteers who are a part of the Mountainside family are your friends and neighbors. We're your community, your hospital and team, working hard for you.

Hackensack Meridian Health Mountainside Medical Center is proud to continue to provide world-class health care services in a community setting. Our 365 bed medical center has successfully transitioned from a stand-alone facility to being part of Hackensack Meridian Health, the most comprehensive and truly integrated network in New Jersey. Mountainside is a joint venture between Hackensack Meridian Health and Ardent Health Services, one of the country's leading private hospital management companies.

We are looking for a dynamic and passionate Transitional Care Navigator to join the Mountainside Team!

What You'll Do

The Transitional Care Navigator will be responsible for managing patient populations with chronic illness, and/or multiple comorbidities, joint replacements and patients that are part of the BPCI-A program.

The successful candidate will be able to:

• Provide continuity of care guidance and support for patients with chronic illness, joint replacement and those qualifying for the BPCI Advanced program as they receive care throughout the care continuum. Uses knowledge of illness, diagnoses and treatments in comprehensive, assessments of patients.
• Performs patient teaching, patient self-management/self-efficacy coaching and planned care management. Ensures coordination for specialty and other handoffs as necessary.
• Utilizes appropriate resources to gather data and assess patient care needs; makes ongoing assessments of the following domains: physio-biological, cognitive/ emotional, spiritual and social, managing life with chronic disease; identifies problems that could lead to an emergency/crisis situation and takes appropriate action to de-escalate; identifies the need for and coordinates specialists/ consultants; communicates assessment data to appropriate persons; assesses learning needs of patient/significant others; documents assessment data according to clinic standards.
• Plans for and manages a panel of patients; plans interventions appropriate to patients' medical and nursing diagnoses, age, abilities and resources; establishes and implements patient directed learning and disease self-management plan for patient/significant others; documents planning process according to organizational standards
• Coordinates with multiple care managers across the continuum for patient care
• Provides teaching to patients/families related to patient's diagnosis, pathology, medical and nursing treatment plans, discharge needs and health goals with a focus on a patient self-management; documents each element of care per organizational standards.
• Performs other duties as assigned.
• Participate in PI Steering, Patient Safety, and Readmission committees as needed
• Review and report on the entire hospital-wide PI at the monthly PI Committee meetings
• Manage Readiness Rounds including scheduling, coordinating the reports and ensuring follow-up
• Monitor The Joint Commission site for any updates or changes and communicates them to the appropriate committees
• Remain current on measure specifications by participating in webinars, reviewing Q Net questions and answers on a regular basis
• Following analysis of data, identify opportunities for improvement and formulate an action plan in conjunction with appropriate interdisciplinary teams when measures are not met
• Provide education and training regarding abstraction rules, changes/updates, and how to best implement changes to demonstrate compliance with regulatory agencies
• Collaboratively partner with other Core Measure Specialists

· Perform any and all duties as assigned

What You'll Bring

• Bachelors of Science in Nursing, Physical Therapy or Occupational Therapy Degree
• Licensed as a Registered Nurse, Physical Therapist or Occupational Therapist in the State of New Jersey
• 3 or more years of experience in your licensed profession
• Experience with home care preferred
• Excellent patient assessment skills, ability to work collaboratively in team setting, current working knowledge of electronic medical records.
• Ability to manage a variety of concurrent programs and projects effectively while utilizing time, equipment and supplies appropriately

· Proficient in Microsoft Office Products, vendor software systems and electronic medical health records applications.

· Ability to analyze, interpret and display data

· Excellent communication and teamwork skills

· Strong foundation of clinical knowledge

· Ability to work independently

· Strong organizational skills

What We Offer

· Competitive pay

· Medical, dental, and vision insurance

· 401k with Company match

· Company paid basic life insurance and long term disability coverage

· Generous paid time off, including an additional extended illness bank

· 6 Paid Holidays

· Tuition Reimbursement

· Advancement and career development opportunities

Hackensack Meridian Health Mountainside Medical Center is an Equal Opportunity Employer and applicants will receive consideration for employment regardless of race, color, age, national origin, religion, sexual orientation, and gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

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