RN, Care Transitions Coordinator (onsite) Evenings, 16 hours a week

Holy Name Medical Center; Teaneck Township (NJ); On-site; USD 60,000 - 90,000; Part time

Job summary

An established industry player seeks a dedicated RN Care Transitions Coordinator to join their team. In this pivotal role, you will facilitate and coordinate patient care services, ensuring quality and cost-effective care while lowering Length of Stay and enhancing patient outcomes. Your expertise will be vital in discharge planning and disease management, collaborating with an interdisciplinary team to provide comprehensive support. This is a fantastic opportunity to make a meaningful impact in healthcare, working within a mission-driven environment that values compassion and innovation. If you are passionate about patient care and ready to take on a rewarding challenge, this role is for you.

Qualifications

• 3-5 years experience in an acute care setting required.
• Disease management and discharge planning experience preferred.

Responsibilities

• Facilitate and coordinate services for patients through the continuum of care.
• Ensure appropriate utilization of resources and safe delivery of care.

Skills

Analytical Skills

Problem Solving

Verbal Communication

Written Communication

Education

Bachelor's Degree in Nursing (BSN)

Job description

RN, Care Transitions Coordinator (onsite) Evenings, 16 hours a week

Location: Teaneck, NJ, United States
Date Posted: Feb 21, 2025

Welcome to Holy Name, a medical center where innovation is not just a goal — it's a commitment. Here, medical excellence thrives, allowing hope to reign supreme and leaving no room for fear. At our hospital, every patient is cared for with undivided attention — because healing every soul is our sole focus.

Holy Name is New Jersey's only independent Catholic health system, comprising a 361-bed acute care hospital, a renowned cancer center, a state-of-the-art fitness center, a residential hospice, a prestigious nursing school, and an extensive physician network. Healing at Holy Name goes beyond medicine and technology – it is infused with faith, conviction, compassion, and a commitment to educating the next generation of healthcare professionals through graduate medical education, a Pharmacy Residency Program, and our Institute for Simulation Learning. Our mission to provide care for the body, mind, and soul spans education, prevention, diagnosis, treatment, rehabilitation, and overall wellness. This is at the core of who we are and what we do, and we've done it this way across generations, every single day, for nearly 100 years. Every innovation, medical breakthrough, and groundbreaking treatment is powered by some of the best minds in medicine, ensuring nothing is left on the table or the road to recovery.

A Brief Overview
The Care Transitions Coordinator is responsible for facilitating and coordinating services for patients through the continuum of care. The Care Transitions Coordinator ensures appropriate utilization of resources and safe delivery of care to all patients and provides quality and cost-effective care that will lower Length of Stay (LOS) and decrease the fragmentation of services that can potentially compromise patient care. Care Transitions Coordinator collaborates efforts as a team in order to perform one or more of the following roles: Discharge Planning and Disease Management of acute and chronic conditions, facility placement needs as needed and timely referrals and evaluations of all post-acute care needs. The Care Transitions Coordinator plays a pivotal role for patients as part of the interdisciplinary team in order to ensure patient safety, quality of care and positive patient outcomes. Rotation of coverage for weekends and holidays will be required and are assigned throughout the year.

What you will do

• Modification of plan of care, as necessary, to meet the ongoing needs of the patient.
• Communicate relevant information to third party payors and the care team.
• Completion of all required documentation in patient records.
• Issues Notices of Non-Coverage per hospital policy.
• Refers appropriate cases for social work intervention based on department criteria.
• Verifies patient demographics and insurance information is correct.
• Expedites execution of plan of care for patients in Observation units.
• Arranges transportation for patients slated for discharge.
• Uphold compliance of regulatory standards for Observation patients including CMS requirement for Code 44.
• Utilizes “Patient Choice” list for support services post discharge and documents.
• Initiates home care referrals for VNS, orders durable medical equipment and arranges ambulance transportation as needed for patients prior to discharge or transfer to another facility.
• Participates as an active, informative and cooperative team member of the health care staff by attending discharge rounds for case finding/follow up and participating in the discharge plan while acting as an advocate for the patient. Arranges family meetings to assist in discharge planning as indicated.
• Other duties as assigned.

Education Qualifications

• Bachelor's Degree BSN Preferred.

Experience Qualifications

• 3-5 years experience in an acute care setting Required.
• Disease Management and Discharge planning experience Preferred.

Knowledge, Skills, and Abilities

• Analytical and problem solving along with excellent verbal and written communication skills.

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure Upon Hire Required.

Holy Name is a mission-driven facility whose quality standards and philosophy are rooted in the principles of its founders, the Sisters of St. Joseph of Peace. Those principles are exercised daily by the Medical Center's dedicated and talented team of physicians, nurses, allied health employees, and a wide variety of non-clinical administrative and operational staff members. Holy Name is an Equal Opportunity Employer.