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RN, Transitional Care Coordinator (FT days)

RN Transitional Care Coordinator (FT days)
Job Number: REQ39417-POS40053
Category: Nursing
Location: Belleville, NJ
Disease Specific Care Coordinator assist in the progression of patient's care during their hospitalization, evaluates and arranges for patient's transition from the hospital into the community or alternate healthcare setting, to reduce avoidable readmissions and improve patient outcomes.
Essential Functions/Responsibilities:
  • Complete psychosocial and discharge planning assessment within 24 hours from admission/referral
  • Make necessary referrals to skilled nursing facilities, homecare agencies, dialysis centers, APN Home visit and other community based healthcare agencies as identified
  • Perform initial assessment or refer to SW for acute Congestive Heart Failure/AMI patients and follow up with placement in the community
  • Participate in interdisciplinary rounds with focus on progression of plan of care, make required phone calls (for population), set up outpatient appointments and needed medical equipment.
  • Collaborate with Utilization Review Nurse on length of stay and progression of plan of care
  • Document all patient education (Disease Specific Packet), assessments and discharge planning interventions in appropriate computer system (i.e.: Cerner, Midas, Tracker)
  • Ensure Medicare Important Message and appeals, termination of benefits, Advance Beneficiary Notice of Non-coverage are provided and reviewed within allotted timeframe
  • Participate in family meetings/ end of life care/palliative care discussions (can refer to Complex Care Coordinator for additional support/guidance as needed)
  • Assess for all forms of abuse and make necessary referrals to APS and DCPP (refer to Complex Care Coordinator for support/guidance as needed)
  • Work with insurance companies in obtaining necessary authorizations and benefit information
  • Assist primary care nurse on EMTALA transfers as needed (i.e. Transportation)
  • Attend required DSRIP education
  • Collects data
Licensure in good standing as a Registered Nurse in the State of New Jersey.
• BSN preferred.
• CHF / AMI Disease Management and patient quality experience required
• Four years recent RN experience in acute care hospital setting working with CHF / AMI patients required.
• Bilingual (Spanish, English) preferred
• Excellent written/oral, listening and organization skills
• Data management experience preferred
• Ability to work with multidisciplinary team
• Computer literate

Company Description:

Barnabas Health is New Jersey’s largest integrated health care delivery system, providing treatment and services to more than two million patients each year. Throughout Barnabas Health, our dedicated physicians, nurses, and health professionals are committed to providing the highest quality of patient care and health education to the community and region.


Barnabas Health offers a broad depth and breadth of services and is one of the leading health care systems in the nation, receiving widespread recognition for clinical excellence and patient safety. Barnabas Health’s network includes seven acute care hospitals, two children’s hospitals, a behavioral health center, including a statewide behavioral health network, ambulatory care facilities, geriatric centers, specialized women’s health services, and comprehensive home care and hospice services. Our 5,200 doctors and 21,000 employees deliver top quality care to 1.5 million outpatients, 220,000 inpatients, and 540,000 Emergency Department patients, and deliver 20,000 babies each year.


We want our patients and their families to know that they can expect the highest level of care, delivered cost-effectively, wherever they see the name Barnabas Health. Each Barnabas employee contributes to a culture of responsibility, improvement, and quality at every one of our facilities, every day.


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