Clinical Navigator; RN Stroke Transitions of Care

Job Title:

Clinical Navigator RN

Location:

Newark Beth Israel Medical Center

Department: FDN HFNJ Comp Stroke

Req #:

Status:
Salaried

Shift: Day

Pay Range: $ – $ per year

Job Type: Full‑Time

Required License/Certification:
Registered Nurse (RN) in New Jersey

Pay Transparency:
The above reflects the anticipated annual salary range for this position if hired to work in New Jersey.

The compensation offered to the candidate selected for the position will depend on several factors, including the candidate's educational background, skills and professional experience.

First established in 1901, Newark Beth Israel Medical Center is a 665‑bed qua ternary care, teaching hospital that provides comprehensive health care for the region. Staffed with more than 800 physicians, 3,200 employees, and 150 volunteers, our hospital is ready to provide you and your family with the quality care you need. At Newark Beth Israel Medical Center, we are committed to quality and excellence in patient care.

Our goal is to exceed your expectations and to provide you an environment that is conducive to healing and promotes patient safety. The Newark Beth Israel Medical Center management and staff abide by the philosophy that all patients are to be treated with respect, dignity, and sensitivity.

Highly motivated and compassionate Registered Nurse (RN) to serve as a Stroke Transitions of Care (TOC) Coordinator. This crucial role is designed to ensure seamless, coordinated, and high‑quality care as stroke patients move between different care settings from acute hospitalization to rehabilitation, skilled nursing facilities, or back to their homes/primary care providers. The Transitions of Care RN acts as a patient advocate and liaison to minimize fragmentation of services, prevent avoidable readmissions, and improve overall patient outcomes.

• Current, unrestricted Registered Nurse (RN) license in the State of New Jersey
• Bachelor's Degree in Nursing (BSN)
• Minimum of 2 years of recent clinical experience in neuroscience, stroke care, rehabilitation, case management, or a similar transitions of care role
• Strong knowledge of stroke standard of care, clinical practice guidelines, and quality measures
• Excellent assessment, critical thinking, organizational, and time‑management skills
• Exceptional communication and interpersonal skills, with the ability to build relationships with patients, families, and multidisciplinary teams
• Proficiency in electronic health records (EHR) and standard computer applications
• NIH Stroke Scale (NIHSS) certification or ability to obtain within a specified timeframe of hire

• Master's degree in Nursing or a related field
• Certification as a Stroke Certified Registered Nurse (SCRN), Certified Rehabilitation Registered Nurse (CRRN), or in Case Management (CCM)
• Experience in patient education and counseling

• Full‑Time, 37.5 Hours
• Occasionally work evening or weekend hours business hours to attend, lead community and staff related education events

• Care Coordination & Planning:
  Screen all eligible stroke patients for the TOC program and develop an individualized transition plan in collaboration with the patient, family, caregivers, and the interdisciplinary healthcare team (physicians, therapists, social work, etc.),
• Patient & Family
  
  Education:
  
  Provide comprehensive education to patients and families regarding the stroke disease process, signs and symptoms of recurrent stroke, medication management, risk factor modification, and rehabilitation skills to promote independence and self‑care,
• Liaison & Communication:
  Collaborate with case management and social work departments to facilitate communication between the acute care team, post‑acute care providers, community resources, and primary care physicians to ensure all involved parties have current and up‑to‑date patient information and discharge plans,
• Follow‑Up & Monitoring:
  Conduct post‑discharge follow‑up, which may include phone calls (e.g., within 24‑48 hours of discharge) or follow‑up visits, to assess patient needs, address barriers to care, and ensure adherence to the established care plan,
• Resource…