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Position Summary

This system-wide, hospital-based position establishes goals, objectives and plans to guide the development and implementation of a comprehensive transition of care model to ensure the appropriate utilization of resources, provision of discharge planning services and social work services. Assists, facilitates, coordinates and in some aspects directs system-wide operations for the continuum of care relative to strategies, program development, planning, and evaluation and compliance initiatives.

Primary Position Responsibilities

1. Foster a comprehensive, cohesive and coordinated approach to the care of patients, ensuring safe, cost effective and quality driven outcomes across the spectrum of the healthcare system, including, but not limited to: Physicians; Specialists; Primary Care Physicians; PCMHs; Home Health Agencies; Acute and Subacute Rehab; LTACH, Skilled Nursing Facilities and Assisted Living.

2. Provide leadership in planning, developing, organizing, implementing and evaluating continuum of care services in terms of overall system goals of clinical quality, value and patient satisfaction.

3. Direct an interdisciplinary and cross-functional Care Coordination team in the assistance, facilitation and coordination of discharge planning and utilization of all potential resources.

4. Ensure the discharge plan is specialized to the unique needs and risk scores of the patient/family/caregiver and that patient preference is always presented for options for post- hospital levels of care.

5. Collaborate closely with the Physician Advisor, Hospitalist Director and Supervisor of Social Work to reduce LOS and increase opportunity days, by ensuring that all inpatient clinical resources are utilized and effectively managed through frequent, timely team meetings, attendance at Interdisciplinary Rounds with Care Coordination and multi-disciplinary team.

6. Foster patient/family/caregiver engagement in all processes associated with transitions of care and patient experience with continuous improvement and development of programs based on both HCAHPS and Press Ganey data analysis and patient feedback.

7. Ensure that Transitions of Care initiatives are implemented and executed via a daily strategic process, involving a coordinated collaborative with MHCC and Practice Managers across the Integrated Delivery System, with efforts geared towards cost-effectiveness, reductions in readmissions, decreased use of the ER and overall improvement in patient centric care.

Qualifications

Minimum Education:

Required:

? Bachelor’s Degree in Nursing and Master's Prepared. If not Mastered Prepared must be enrolled upon hire and complete within 5 years.

Preferred:

? Certificate and/or Advanced Specialized or Specialty Training in Care Coordination or Case Management.

Minimum Years of Experience (Amount, Type and Variation):

Required:

? Five years clinical experience

3-5 years management experience in an acute care setting

Preferred:

? One to two years management experience, preferably in an acute care medical setting, to include direction of Care Coordination and/or Case Management.

License, Registry or Certification:

Required:

? Current New Jersey RN

Preferred:

? Case Management/ Care Coordination Certification or ACSW certification

Knowledge, Skills and/or Abilities:

Required:

? Excellent verbal and written communication skills, excellent team building and team leadership skills, ability to facilitate strong interdisciplinary collaboration, strong knowledge base of health care delivery systems, health care social work, discharge planning and community resources. Strong internal and external relationship/networking skill set.

? Knowledge of current concepts in Care Coordination. Population Health, Social Work/Social Services, Case Management and Discharge Planning with demonstrated experience in patient care evaluation methodologies, criteria development and data analysis techniques and applications.

Hunterdon Health is committed to providing a competitive benefit package to our employees. Benefit offerings vary based on status and may include but not be limited to medical, dental, vision, family forming, paid time off, tuition reimbursement, and retirement savings.

The hiring range listed is the potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement. When determining an applicant’s hourly rate and/or base salary, several factors may be considered as applicable (e.g., years of relevant experience, education, internal equity, and specialty).