Clinical Navigator (RN) Stroke Transitions of Care

Job Title: Clinical Navigator RN

Location: Newark Beth Israel Medical Ctr

Department Name: FDN HFNJ Comp Stroke

Req #: 0000237364

Status: Salaried

Shift: Day

Pay Range: $106,563.89 - $139,288.37 per year

Job Type: Full-Time

Required License/Certification: Registered Nurse (RN) in New Jersey

Key Responsibilities

Care Coordination & Planning: Screen all eligible stroke patients for the TOC program and develop an individualized transition plan in collaboration with the patient, family, caregivers, and the interdisciplinary healthcare team (physicians, therapists, social work, etc,

),

Patient & Family Education: Provide comprehensive education to patients and families regarding the stroke disease process, signs and symptoms of recurrent stroke, medication management, risk factor modification, and rehabilitation skills to promote independence and self-care,

Liaison & Communication: Collaborate with case management and social work departments to facilitate communication between the acute care team, post-acute care providers, community resources, and primary care physicians to ensure all involved parties have current and up-to-date patient information and discharge plans,

Follow-Up & Monitoring: Conduct post-discharge follow-up, which may include phone calls (e,

g,

, within 24-48 hours of discharge) or follow-up visits, to assess patient needs, address barriers to care, and ensure adherence to the established care plan,

Resource Management: Maintain current knowledge of community resources and make appropriate referrals (e,

g,

, to home health agencies, primary care providers, behavioral health services, transportation assistance) to support the patient's recovery and enhance clinical outcomes,

Quality Improvement: Participate in data collection, analysis, and reporting of stroke quality metrics related to transitions of care, patient experience and readmission rates,

Identify and refer quality issues for review and participate in performance improvement activities,

Regulatory Compliance: Ensure all transitional care activities comply with state, Joint Commission, and CMS requirements and standards,

Pay Transparency:

The above reflects the anticipated annual salary range for this position if hired to work in New Jersey.

The compensation offered to the candidate selected for the position will depend on several factors, including the candidate's educational background, skills and professional experience.

Overview

First established in 1901, Newark Beth Israel Medical Center is a 665-bed quaternary care, teaching hospital that provides comprehensive health care for the region. Staffed with more than 800 physicians, 3200 employees, and 150 volunteers, our hospital is ready to provide you and your family with the quality care you need. At Newark Beth Israel Medical Center, we are committed to quality and excellence in patient care. Our goal is to exceed your expectations and to provide you with an environment that is conducive to healing and promotes patient safety. The Newark Beth Israel Medical Center management and staff abide by the philosophy that all patients are to be treated with respect, dignity, and sensitivity.

Job Summary

Highly motivated and compassionate Registered Nurse (RN) to serve as a Stroke Transitions of Care (TOC) Coordinator,

This crucial role is designed to ensure seamless, coordinated, and high-quality care as stroke patients move between different care settings from acute hospitalization to rehabilitation, skilled nursing facilities, or back to their homes/primary care providers,

The Transitions of Care RN acts as a patient advocate and liaison to minimize fragmentation of services, prevent avoidable readmissions, and improve overall patient outcomes,

Qualifications:

• Current, unrestricted Registered Nurse (RN) license in the State of New Jersey,
• Bachelor's Degree in Nursing (BSN),
• Minimum of 2 years of recent clinical experience in neuroscience, stroke care, rehabilitation, case management, or a similar transitions of care role,
• Strong knowledge of stroke standard of care, clinical practice guidelines, and quality measures,
• Excellent assessment, critical thinking, organizational, and time-management skills,
• Exceptional communication and interpersonal skills, with the ability to build relationships with patients, families, and multidisciplinary teams,
• Proficiency in electronic health records (EHR) and standard computer applications,
• NIH Stroke Scale (NIHSS) certification or ability to obtain within a specified timeframe of hire,

Preferred:

• Master's degree in Nursing or a related field,
• Certification as a Stroke Certified Registered Nurse (SCRN), Certified Rehabilitation Registered Nurse (CRRN), or in Case Management (CCM),
• Experience in patient education and counseling,

Scheduling Requirements:

• Full-Time, 37.5 Hours
• Occasionally work evening or weekend hours business hours to attend, lead community and staff related education events

Essential Functions:

• Care Coordination & Planning: Screen all eligible stroke patients for the TOC program and develop an individualized transition plan in collaboration with the patient, family, caregivers, and the interdisciplinary healthcare team (physicians, therapists, social work, etc,),
• Patient & Family Education: Provide comprehensive education to patients and families regarding the stroke disease process, signs and symptoms of recurrent stroke, medication management, risk factor modification, and rehabilitation skills to promote independence and self-care,
• Liaison & Communication: Collaborate with case management and social work departments to facilitate communication between the acute care team, post-acute care providers, community resources, and primary care physicians to ensure all involved parties have current and up-to-date patient information and discharge plans,
• Follow-Up & Monitoring: Conduct post-discharge follow-up, which may include phone calls (eg within 24-48 hours of discharge) or follow-up visits, to assess patient needs, address barriers to care, and ensure adherence to the established care plan,
• Resource Management: Maintain current knowledge of community resources and make appropriate referrals (e, to home health agencies, primary care providers, behavioral health services, transportation assistance) to support the patient's recovery and enhance clinical outcomes,
• Quality Improvement: Participate in data collection, analysis, and reporting of stroke quality metrics related to transitions of care, patient experience and readmission rates,
• Identify and refer quality issues for review and participate in performance improvement activities,
• Regulatory Compliance: Ensure all transitional care activities comply with state, Joint Commission, and CMS requirements and standards

Benefits and Perks

At RWJBarnabas Health, our employees are at the heart of everything we do. Driven by our Total Wellbeing promise, our market-competitive offerings include comprehensive benefits and resources to support our employees’ physical, emotional, financial, personal, career, and community wellbeing. These benefits and resources include, but are not limited to:

• Paid Time Off including Vacation, Holidays, and Sick Time
• Retirement Plans
• Medical and Prescription Drug Insurance
• Dental and Vision Insurance
• Disability and Life Insurance
• Paid Parental Leave
• Tuition Reimbursement
• Student Loan Planning Support
• Flexible Spending Accounts
• Wellness Programs
• Voluntary Benefits (e.g., Pet Insurance)
• Community and Volunteer Opportunities
• Discounts Through our Partners such as NJ Devils, NJ PAC, and Verizon
• ….and more!

Let’s shape the future of healthcare, together. Our competitive base rates offered will be dependent upon your relevant experience, education and skills. In addition to base salary, we offer excellent benefits, creating a competitive total rewards package to include health and welfare benefits, tuition reimbursement, retirement benefits, employee assistance programs, and many opportunities for professional and personal growth.

Choosing RWJBarnabas Health!

RWJBarnabas Health is the premier health care destination providing patient-centered, high-quality academic medicine in a compassionate and equitable manner, while delivering a best-in-class work experience to every member of the team. We honor and appreciate the privilege of creating and sustaining healthier communities, one person and one community at a time. As the leading academic health system in New Jersey, we advance innovative strategies in high-quality patient care, education, and research to address both the clinical and social determinants of health.

RWJBarnabas Health aims to truly make a unique impact on local communities throughout New Jersey. From vastly improving the health of local residents to creating educational and career opportunities, this combination greatly benefits the state. We understand the growing and evolving needs of residents in New Jersey—whether that be enhancing the coordination for treating complex health conditions or improving community health through local programs and education.

Equal Opportunity Employer

RWJBarnabas Health is an Equal Opportunity Employer