Job Overview-

The Transitional Care program provide services to patients with chronic diseases such as Heart Failure, Chronic Obstructive Pulmonary disease, Diabetes, uncontrolled Hypertension, whose medical and/or psychosocial problems require moderate or high-complexity medical decision making during transitions in care from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), to the patient s community setting (home, and or assisted living). The APN will also follow up with patients 18 years old and over within 24 to 72 hours after discharged home.The Nurse practitioner will gather these patients daily and sample them on a daily patient log, review patient s history and physical/ consults. In additon to assessing inpatient and family understanding of their disease, educate and collaborate needs with the Care Transition Team.

Qualifications:

Required:

Master s degree in Nursing required.
Registered Professional Nurse with current NJ state license; CDS and DEA.
CPR certification.
NP Certification.
Three to five years of work experience as a professional nurse.
SPANISH LANGUAGE PROFICIENCY REQUIRED FOR THIS POSITION

Scheduling Requirements:

Full time
40 hours

Essential Functions:

Communicate with home health agencies and other community services utilized by the patient and/or family/caretaker. Organizing and arranging referrals of needed community resources.
Educate patient/ family/ guardian, and/or caregiver to support self-management, independent living, and activities of daily living.
Support for Medication management and other treatment regimen adherence, Identification of available community and health resources
Facilitating access to care and services needed by the patient and/or family
Obtaining and reviewing the discharge information (e.g., discharge summary and medication reconciliation)
Reviewing need for, or follow-up on treatments
Interaction with other qualified health care professionals who will assume the care of the patient after discharge by assisting in scheduling any required follow-up with patients with their providers and community services.
Home visits are required.

At RWJBarnabas Health, our market-competitive Total Rewards package provides comprehensive benefits and resources to support our employees physical, emotional, social, and financial health.

Paid Time Off (PTO)
Medical and Prescription Drug Insurance
Dental and Vision Insurance
Retirement Plans
Short & Long Term Disability
Life & Accidental Death Insurance
Tuition Reimbursement
Health Care/Dependent Care Flexible Spending Accounts
Wellness Programs
Voluntary Benefits (e.g., Pet Insurance)
Discounts through our partners such as NJ Devils, NJ PAC, Verizon, and more

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 in 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