Post Acute Care Coordinator (Central/Northern Regions)

Job Overview:

As part of RWJ Barbanas Health Corporate Population Health team team you will play an instrumental role in a department that is providing fully coordinated patient care from a holistic approach to improve the overall care of patients who are part of the value-based, ACO, and bundled payment programs across the healthcare continuum by ensuring the population receives the right care, at the right time, by the right team. As a member of the patients multidisciplinary team in the Post Acute setting, the Post-Acute Care Coordinator – LPN, RN, PT, OT or SW evaluates the treatment plan and goals of care at the Post-Acute Care facility. The Post-Acute Care Coordinator partners with the clinical team at the Post-Acute care facilities to ensure patients are progressing towards discharge goals as well as coordinating next site of care discharge planning and ensure timely follow up with providers and service in the community. The Post-Acute Care Coordinator also works with other Population Health programs to assist patients in transitioning to the next site of care.

Qualifications:

Required:

• LPN- Associates Degree; RN- Associates Degree; Physical Therapy- Bachelor’s Degree; Occupational Therapy- Bachelor’s Degree
• 3-5 years experience in managing relationships between acute and post-acute facilities
• Must have the ability to travel to post-acute sites and hospital sites.
• Must have strong organizational skills, with an ability to prioritize multiple tasks and deadlines
• Strong leadership skills to achieve buy-in and collaboration toward objectives

Preferred:

• RN- Bachelor’s Degree; Physical Therapy- Master’s Degree; Physical Therapy- Master’s Degree; Occupational Therapy- Master’s Degree
• Worked in the Post Acute Care Setting
• Knowledge of various Value Based Programs

Licenses Required:

• NJ LPN, RN, Social Worker, Physical Therapy, or Occupational Therapy License

Scheduling Requirements:

• M-F, FT 9:00A—5:00P
• This role will support Middlesex County, Hudson County & Somerset County - subject to change given business need.

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 Care setting to create a collaborative care plan for patients that are 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 the Post Acute Care facilities and their team members and other health care providers as appropriate, providing home instructions, recommending and/or providing equipment/ home modifications, and recommending appropriate follow-up care if needed.
• Provides education to staff by assessing the 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.
• Provide resources and education to Post Acute Care facilities on readmissions.
• Serves as a resource for the Post Acute Care facilities.

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.