RN, Post Acute Care Coordinator

Description

RN, Post Acute Care Coordinator

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 Post Acute Coordinator is responsible for facilitating and coordinating services for patients through the continuum of care. The Post Acute Care Coordinator ensures appropriate utilization of resources and safe delivery of care to all patients and provides quality and cost-effective care resulting in a decrease of the fragmentation of services that can potentially compromise patient care. The Post Acute Care Coordinator collaborates efforts as part of a team in order to facilitate quality, cost effective continuum of care for designated bundled care patients. The Post Acute Care Coordinator will play a pivotal role for patients as part of the interdisciplinary team in order to ensure patient safety, quality of care and positive patient outcomes.


What you will do

• Key position within the CMS Bundled Payments for Care Improvement program for the Major Joint
• Replacement of Lower Extremity Bundle.
• Develop working relationships with hospital interdisciplinary team members including, Case Managers,
• Discharge planners, Social Workers,
• Work with hospital’s case management department to ensure safe discharge to appropriate next site of care;
• including assessment and coordination of post-discharge needs
• Collaborate with partners to identify patients discharging to post-acute facilities, where appropriate
• Serve as a liaison between patient, physicians, staff and rehab facilities, fostering better outcomes and
• efficiency
• Establish contact with the post-acute provider prior to the patient’s discharge and implement plan to ensure
• contact/follow up through the 90 day Post-Acute Care (PAC) phase
• Follow-up on transitional care plan progress with patient and post-acute providers. Provide assessment of
• readmissions to determine cause and develop plan.
• Track patient progress and communication with providers in on-line database. Review and interpret claims
• data from CMS (provided in user-friendly format
• Communicate with patient on an on-going basis to improve healthcare outcomes.(Medication review,
• education, MD follow-up, etc.)
• Assists with pre op phone calls and participation in Joint replacement education class.
• Presents data via google slides, etc. as requested to key stakeholders within the organization for review
• including physician and hospital leadership.
• Meets with partnering SNF's regularly onsite to review LOS data, treatment plans, outcomes or discuss
• challenging patients.
• Assists with high lace post discharge phone calls, intervenes as necessary to prevent readmission.
• Provides coverage when needed in the Continuous Care Department as directed by Continuous Care
• leadership
• Other duties as assigned

Education Qualifications

• Bachelor's Degree BSN Required and

Experience Qualifications

• 3-5 years of 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 Valid NJ RN License Upon Hire Required
• BCLS - Basic Life Support Upon Hire Required
• 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.