Valley Health Systems and CareOne Valley & Emerson have a unique career opportunity for an APN /Nurse Navigator/ Transitional Care Nurse.
Summary: To act as a facilitator of collaboration across the care continuum. To interface with acute care and extended care facilities, foster physician relationships, assist in the coordination and facilitation of clinical review of potential clients. Provides clinical leadership, expertise, collaboration, consultation and mentorship to promote evidence-based nursing practice. To develop and evaluate a program of care using transitional models of care, i.e. Naylor & Coleman.
Competencies:
1) Practices as an autonomous and collaborative member of the healthcare team, demonstrating clinical expertise, differentiating between normal findings and those needing treatment, referral and/or consultation.
2) Evaluates transitional models of care, i.e., Naylor and Coleman, develops patient protocols, and establishes outcomes criteria and measurement in collaboration with long-term, assisted living and sub-acute care facilities, and the Valley Health System.
3) Provides care transition intervention activities in the following domains: Medication self-management and education, personal health record, post hospitalization/skilled nursing discharge physician follow up, and knowledge of “red flags” in care
4) Functions as a Liaison b/w Medicine, Nursing, Patient, and Family and acts as a patient advocate to promote health and well-being within transitions in continuum of care. Utilizes resources as appropriate to prevent readmissions i.e Med Rec, follow-up phone calls, Home care, HF OUTPT Program.
5) Demonstrates advanced assessment skills within clinical specialty, providing evidence-based treatment interventions, to achieve positive outcomes for patients and families.
6) Provides clinical guidance and leadership through participation and/or representation for role specialty at unit, departmental and hospital meetings, committees, councils, task forces, and multidisciplinary rounds, as needed.
7) Prepare and submit timely and accurate data reports on care interventions.
8) Participates in the development and recommendation of evidence-based practice identifying the goal and desired measurable outcomes, which may include clinical, financial, process/system, and patient/family satisfaction.
9) Consults with other health providers on specialty population across all services.
10) Functions as mentor, educational resource, and consultant for staff in area of specialty, providing clinical expertise.
11) Identifies and assists in coordinating the acquisition of any needed special equipment, supplies, or consultations.
12) Conducts pre-admission/re-admission assessment visits, providing the information to assist in the completion of the MDS and initial nursing assessment in accordance with regulatory guidelines.
13) Participates in activities related to clinical outcome data collection, as well as performance improvement.
14) Identifies resident and interdisciplinary team educational needs and confers with clinical education department to provide educational resources to the interdisciplinary team, i.e., articles, handouts, poster, one-on-one teaching, and/or demonstration, and coordinate resident-related in-services.
15) Demonstrates understanding of the health care system and its component parts including levels of care (sites of care) and the roles of various care providers.
16) Performs approved procedures under collaborative practice agreement.
17) Demonstrates understanding that the care for the frail, elderly in long-term care is a complex process requiring team work and close interaction with the Physician/s.
18) Demonstrates timely exchange of clinical information to Physician/s. Takes calls from the extended care facility on designated residents and contacts the Physician when necessary and as agreed upon with the Physician.
19) Maintains readily available patient database. Coordinates and facilitates specialty appointments and communication between specialists and the primary Physician.
20) Conducts alternate regulatory visits if the Physician/facility desire allowing the Physician to focus on residents with active medical problems.
21) Demonstrates knowledge and ability to discuss important issues, such as advanced directive, with residents, family members, and facility staff.
Education: Masters Degree/MSN Program which includes Pharmacology in its required curriculum. Certification as a Nurse Practitioner in the State of New Jersey, Clinical Nurse Specialist, or Advanced Practice Nurse by a national accrediting organization, which is approved by the Board.
Experience: Two plus years of clinical experience in the home health setting, acute care setting, skilled nursing facility, physician’s office or in a community setting.
Skills/Certifications: Current and valid NJ State Professional Registered Nurse license. Certification through NJ State Board of Nursing, in accordance with the NJ Advanced Practice Nurse Certification Act..National or Board Certification as appropriate in area of specialty. American Heart Association Basic Life Support Healthcare Provider Certification. Collaborating Physician(s) of Record, as per the APN Act and Regulations, if appropriate to role. Demonstrates effective interaction and communication (oral, writing, presenting) skills. Effective organization skills and ability to perform work accurately and pay attention to details, often changing from one task to another without loss of efficiency or composure. Ability to function competently in stressful situations and a changing work environment related to changing patient needs, including working with patients with acute, chronic, and complex disease processes, and those who are dying. Ability to work cooperatively within the health-system; with patients and family members; and with multidisciplinary team members. Ability to utilize effective time management to set priorities, perform job related responsibilities, and respond quickly to emergency situations. Ability to use critical thinking and clinical reasoning skills effectively problem-solve and deliver care. Reliable and applicable transportation as it relates to the responsibility of the job. Driver`s License - current and valid driver`s license, registration and insurance coverage required for all vehicles being driven for VHC business. Employees must adhere to all procedural guidelines in HR Policy 108 including demonstrating an acceptable driving record for the duration of their employment as long as driving continues to be a responsibility of the job. 
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