Nurse Practitioner (FT) Day Transition of Care Clinic, Newark

Job Overview:

The Transitions of Care Advanced Practice Provider works closely with the interdisciplinary transitions of care team at NBI, including physicians, nurses, pharmacists, and care coordinators, to improve healthcare outcomes for patients discharged from the hospital with the goal of reducing hospital readmissions,

The ToC APP focuses on coordinating care and care plans for inpatients at high risk of readmission across the in-patient and out-patient phases of care,

Qualifications:

• Current NJ APN license required
• CDS & DEA required
• BSN required
• BLS & ACLS required

Scheduling Requirements:

• Full Time
• Day Shift
• 40 Hours

Essential Functions:

• In collaboration with the transition care team identify and manage high-risk in-patients by assuring there are individualized care plans based upon clinical knowledge in disease management, prevention, health risk, self-care and case management
• proactive outreach to complex high-risk patients to create and manage their plan of care including medication reconciliation, disease education, and coordination of services
• contact and manage patients who experience a transition of care in-patient stay or ED visit within 48 hours ensuring the medical, psychosocial and functional assessments are completed after discharge and appropriate follow up is scheduled
• monitor that appropriate services and care are in place and being delivered
• assure best practice guidelines for prevention and disease management are in place
• Consistently provides comprehensive, community-based, patient-centered, developmentally appropriate, and culturally and linguistically appropriate care coordination and team based care to patients
• Participate in the care of patients at their immediate 7 day post discharge visit
• Participate in quality improvement initiatives, tracking and reporting patient outcomes

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.