Post Acute Care Coordinator (Central Region)

at  RWJBarnabas Health

Req #: 0000173341
Category: Nurse Case Manager
Status: Full-Time
Shift: Day
Facility: RWJBarnabas Health Corporate Services
Department: Accountable Care Organization

ESSENTIAL FUNCTIONS:

• Performs initial and on-going assessments of patient’s condition during and after a post acute episode.
• Establishes, revises and evaluates a plan of care which is appropriate to problems identified and involves the patient/family.
• Participates in multidisciplinary rounds with the clinical team in the Post Acute setting to create a collaborative care plan for patients that is patient and family centered, follows evidence based clinical guidelines and promotes the best outcome for the patient.
• Provides for continuity of care by participating in discharge planning with patients, families and other health care providers as appropriate, providing home instructions to patients and caregivers, recommending and or providing equipment/ home modifications, and recommending appropriate follow-up care if needed.
• Provides education to patient/family/staff by assessing patient/family educational needs.
• Maintains appropriate documentation that details the patient’s response to therapy and the need for skilled intervention as outlined by regulatory bodies.
• Serves as a resource for the Post Acute facilities in finding and scheduling follow up providers, specialists, and services across the RWJ Barnabas medical neighborhood.

OTHER DUTIES:

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