Capital Health is the region's leader in advanced medicine with significant investments in advanced technologies and the best physicians. Comprising its two hospitals (Capital Health Regional Medical Center in Trenton and the Capital Health Medical Center - Hopewell) and the Capital Health - Hamilton outpatient facility, Capital Health is a growing healthcare organization that is accredited by The Joint Commission. Capital Health has also received Magnet® status for the fourth consecutive time in recognition of its quality patient care, innovations in professional nursing practice, and nursing excellence. Only 29 organizations in the country have received Magnet status four times and five of those organizations are in New Jersey. In addition, our nursing team received special recognition for excellence in stroke and outpatient emergency care.
Assesses patients on assigned units within 24 hours of admission. Assessments to include review of the treatment plan, determination of the level of care, assessment of discharge needs, and initiation of the discharge plan process.
Develops and implements a discharge plan proactively through collaboration with physicians, patients, families, multidisciplinary team members and other external caregivers (as applicable) to facilitate a seamless transition from one level of care to another across the healthcare continuum.
Conducts daily rounds on assigned unit with charge nurse or designee to ensure that the multidisciplinary plan of care is consistent with the patient's clinical course, continuing care needs and covered services.
Reassesses continually the plan of care and discharge needs of the patient, and collaborates with the members of the multidisciplinary team to modify the plans as needed based on the patient's changing needs.
Maintains a working knowledge of behavioral responses to illnesses and other areas (community resources, payer requirements) to facilitate the patient's movement along the healthcare continuum, as demonstrated by participation in ongoing continued education with a minimum of 15 CEUs per year.
Maintains documentation in the medical record and in computer systems as required by policy or departmental practice.
Makes all referrals needed to implement the discharge plan, which includes LTACH, post-acute facilities and home care on a timely basis. Follows up to ensure that the services needed by patients/families are in place prior to discharge.
Identifies, develops and implements strategies to reduce length of stay and resource consumption.
Handles daily assessment of patient hospital course to proactively identify issues with completion and reporting of diagnostic testing, completion of treatment for the acute episode of care, facilitation of appropriate level of care, and utilization of resources, discussing estimated LOS for diagnosis and communicating the discharge plan.
Works with the multidisciplinary team when issues are identified to facilitate appropriate interventions. Collects data on the variances for analysis on daily reports.
Identifies issues that have a negative impact on patient care and reports these issues to the responsible entity. Identifies and advises manager/director when physician or patient issues require legal, ethical or administrative interventions. Participates in performance improvement activities in the management of patient care as demonstrated in monthly PI reports.
Valid NJ RN license.
Three years' experience in a clinical nursing environment.
Experience in case management field, including utilization review, discharge planning, outcomes management, assessment care planning and care coordination.
Word-processing and spreadsheet skills.
Low employee expense for medical and dental insurance
403(b) Savings and Retirement Program
Easy commute from PA and major NJ routes.
Find out why our 3000+ employees have chosen Capital Health.