Transition Assistant - Accountable Care - Licensed Practical Nurse - Hackensack Meridian Health

Our team members are the heart of what makes us better.

At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community.

Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.

As a part of the population health team, the Transition Assistant - ACO, Licensed Practical Nurse, is responsible for assigned patient care and related administrative duties under the direct supervision of a licensed healthcare practitioner. Responsibilities for this role include patient education and outreach, follow-up phone calls for disease management, managing patients at risk for readmissions, assisting in quality audits, and other duties as assigned. Inpatient TA ACO LPN will focus on increasing enrollment in the HMH Population Health Care Management Programs offered post-discharge, as well as focusing on disease management and prevention of readmissions in the MSSP and attributed value-based populations. The IP-TA will work under the direction of the Pop Health Manager-Central, and will visit all attributed, admitted MSSP and value-based patients and will share patient information from previous touches, if any, by the Population Health Care Coordination Team. IP-TA will work collaboratively with the inpatient case manager and the rest of the interdisciplinary team to ensure a safe transition from the hospital to the next level of care. The IP-TA will share the name of the nurse that will follow the patient once discharged, and will do a warm handoff to that nurse as needed. Population: MSSP and attributed value-based patients admitted to a Central Region HMH facility.

This position is 50% in office and 50% remote.

A day in the life of a Transition Assistant - ACO, Licensed Practical Nurse at Hackensack Meridian Health includes:

• Works in collaboration with the care manager to support and coach patients through identifying or recommending in network, community based assistance, or support programs to help meet patient goals.
• Participates in making follow-up phone calls to target population as directed by care manager.
• Monitor that appropriate home care, hospice care and other ancillary services (DME, infusion services, etc.) are in place and are being delivered as directed by the care team for low and rising risk patients post discharge.
• Where applicable, coach and communicate with patients to ensure they are aware of discharge instructions, have necessary prescriptions and access to medications.
• Reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse.
• Managing lower risk patients not attributed to the high risk outpatient care managers.
• Embedment or travel to various office settings (i.e., physician practice, patient home, acute/post-acute settings).
• Identifies patient complaints or issues that must be reported to the appropriate person (i.e., clinician, social worker, care manager, or supervisor).
• Engages in patient advocacy, empowers patients to take charge or leadership in their healthcare, and coaches patients to ask questions to understand their disease process as well as their care plan.
• Performs technical, administrative, and clerical duties as directed by the licensed healthcare practitioner and within the scope of training and certification.
• Documents data and care in the population health care management system and maintains confidentiality.
• Compliant with Recognized Standards or Guidelines for Practice, Service Specific Policies and Regulatory Agencies/Standards governing departmental services/operations.
• Uses pertinent performance metrics to drive improvement in practice that will enhance patient or consumer safety, satisfaction, efficient and effective care.
• Identify and promote best practices.
• Identify and participate in the development of strategies to reduce unnecessary utilization and readmission resource consumption.

Additional Essential Generic Job Functions: Inpatient

• Must be on-site at HMH-assigned facilities 5 days per week.
• Utilizes Healthy Planet facility patient lists to identify admitted patients.
• Documents their interactions with patients, families, and other staff members in Healthy Planet.
• The program will start with MSSP-attributed beneficiaries only, at one HMH Facility.
• The program will branch out to other central HMH Facilities and other value-based attributed patients.
• Visits admitted patients no sooner than 36 hours post-admission to ensure the inpatient case manager has seen and assessed the patient.
• Engages and encourages patients and their families to take an active role in their health by providing them with information about the population health programs offered by the care coordination team, reviews the services available, encourages patients and families to agree to services, and gives them the name of the nurse who will follow the patient once discharged.
• Any patient that is a 30-day readmit, regardless of care management risk score will be followed by the community-based RN post discharge
• Any patient that is not a 30-day readmit will be assigned to the community-based RN based on the current care management risk score of the patient.
• IP-TA completes warm hand-off of patient status and post-discharge needs to the community-based RN or TA-LPN to ensure the patient is being received by appropriate providers and services once discharged.
• All data will be reported through Epic reporting on a monthly basis.
• Flexibility in work schedule to accommodate the needs of patients and caregivers. (i.e.9am-5:30 pm, 10am-6:30pm)

Education, Knowledge, Skills and Abilities Required:

• Graduate of an accredited program in Licensed Practical Nursing.
• One to three years of patient care experience.
• Exceptional communication skills to enable communication and collaboration with physician, patients, families, and ancillary staff.
• Ability to work cooperatively with peers and supervisors.
• Excellent critical thinking skills.
• Ability to work in a fast pace team environment.
• Ability to prioritize and multi-task.
• Experience with relevant systems (e.g., electronic medical records, disease registries).
• Proficient computer skills (i.e., Microsoft Office Suite, data entry ability, and clinical programs).

Education, Knowledge, Skills and Abilities Preferred:

• Primary care experience.
• Experience working with seniors.
• Knowledge about population health management and clinical integration principles and processes.
• Bi-lingual or multi-lingual.

Licenses and Certifications Required:

• Current and valid NJ State Licensed Practical Nurse. 

If you feel that the above description speaks directly to your strengths and capabilities, then please apply today!