Communicates internally about relevant patient information concerning the care of specialized patient populations referred to VNSNY as needed. Acts as a resource towards the integration of evidence-based care practices into protocols, policies, consultation strategies, and continuous quality improvement initiatives. Leads the care coordination by assessing identified potential patients to determine eligibility and appropriateness. Collaborates internally to navigate the transition with the patient, family, physician, and care team through the education, evaluation, and decision making.
Will be based in VNSNY office located with in My Sinai Hospital
Identifies potential barriers to care; follows up with VNSNY clinical operations to communicate identified barriers and recommended interventions, as appropriate.
Establishes and promotes an ongoing collaborative relationship with hospital-based providers, including physicians, nurses, and health administers.
Participates in internal and external clinical case review meetings for select patient populations, as needed. Maintains excellent communication and relationships with VNSNY teams.
Serves as clinical lead for case conferences with hospital staff; collaborates with hospital staff to identify barriers to care and VNSNY clinical operations intervention solutions. Follows up with clinical operations to communicate identified barriers and recommended interventions; reports back to clinical management team at VNSNY on results.
Documents using workflows, procedures and processes in both the electronic record and paper log.
Participates in the root cause analysis of the readmission event in collaboration with VNSNY operations and helps to develop recommendations for quality improvement measures.
Establishes and promotes an ongoing collaborative relationship with direct caregivers, hospital administration, physicians, nurses, discharge planners, case managers, unit clerks, and other facilities personnel.
Provides data to hospital customer, in conjunction with VNSNY management, on progress of the transitional care client adhering to HIPAA and other State and Federal regulations.
Assures that the client has received health education materials to support transitional care as appropriate. Educates the client on how to use these tools.
Assists senior leadership with development of VNSNY client outcomes reporting and other analyses of clinical data and VNSNY quality reporting as needed.
Participates in special projects and performs other duties as required.
Licensure: License and current registration to practice as a Registered Professional Nurse, in New York State required. Valid driver's license may be required, as determined by operational/regional needs.
Education: Bachelor’s degree in Nursing or equivalent work experience required. Master’s degree in Nursing or other health care related field preferred.
Experience: Minimum of two years of clinical nursing experience required. Home care or Hospice experience preferred. Experience in case management, administration or discharge planning experience in a hospital setting preferred. Training in population care coordination preferred. Exceptional customer service skills required. Demonstrated ability to engage clinical counterparts in collaborative discussions required. Strong follow up skills required, as well as the ability to manage multiple priorities. Proficiency in Microsoft Office Suite required. Knowledge of value based care models and managed care preferred. Hospice or palliative care experience preferred. Experience as a patient advocate preferred.
The Visiting Nurse Service of New York (VNSNY) is the nation's largest not-for-profit home- and community-based health care organization, serving the five boroughs of New York City, and Nassau, Suffolk, and Westchester Countries. For over 125 years, VNSNY has been committed to improving the health and well-being of people through high-quality, cost effective healthcare in the home and community. We offer a wide range of services, programs, and health plans to meet the diverse needs of our patients, members, and clients from before birth to the end of life. Each day, more than 13,000 VNSNY employees - including nurses, rehabilitation therapists, social workers, other allied professionals, and paraprofessionals - deliver compassionate care, unparalleled medical expertise, and 24/7 solutions and resources to more than 44,000 patients and members, helping them to live the best lives possible in their homes and communities.