Job Description

As part of a dedicated multidisciplinary team, the transitional care nurse practitioner provides inpatient and outpatient clinical services and works in collaboration to ensure high quality and timely care for patients with COPD and pneumonia.

Responsibilities

• Devises, documents, and maintains a transitional care plan
• Identifies barriers to chronic disease management and provides appropriate intervention
• Refers patients to specialty and ancillary services
• Collaborates with inpatient and ambulatory teams to optimize clinical care
• Follows an assigned cohort of patients for post discharge transitional care management visits via telemedicine or in-person
• Serves as the patient resource for transitional care information and follow-up care coordination during the transition perio d
• Serves as liaison to post acute clinical partners (home care, skilled nursing facilities)
• Engages in performance/quality improvement activities and promotes transitional care excellence throughout system

Qualifications

• Master’s degree in Nursing required, Doctor of Nursing Practice preferred
• Current registration as a Professional Nurse and Nurse Practitioner in New York
• National certification in nurse practitioner specialty (e.g., A-GNP, ANP-BC, CPNP-PC)
• Evidence of excellent interpersonal and communication skills, creative problem solving and excellent critical thinking and leadership
• Previously demonstrated ability to facilitate group processes and work cohesively and collaboratively as member of the interdisciplinary team
• Qualified candidates must be able to effectively communicate with all levels of the organization

Department: Administration Bargaining Unit: NYSNA Campus: MOSES Employment Status: Regular Full-Time Address: 111 East 210th Street, Bronx Shift: Day Scheduled Hours: 9 AM-5:30 PM Req ID: 224323  Salary Range/Pay Rate: $81.37      

For positions that have only a rate listed, the displayed rate is the hiring rate but could be subject to change based on shift differential, experience, education or other relevant factors.

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Montefiore is an equal employment opportunity employer. Montefiore will recruit, hire, train, transfer, promote, layoff and discharge associates in all job classifications without regard to their race, color, religion, creed, national origin, alienage or citizenship status, age, gender, actual or presumed disability, history of disability, sexual orientation, gender identity, gender expression, genetic predisposition or carrier status, pregnancy, military status, marital status, or partnership status, or any other characteristic protected by law. 

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