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RN, Care Transitions Coordinator (days)

Location: Teaneck, NJ, United States
Date Posted:



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.

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
  • Knowledgeable about Indigent Medication Programs
  • 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 and
  • 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 and
  • CCM - Certified Case Manager Upon Hire Preferred

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.