Job Description

Position Summary

The System Stroke Program Coordinator (RN) provides centralized operational leadership for the design, implementation, certification readiness, quality oversight, and sustained performance of the Hudson Regional Health System stroke programs. The coordinator is accountable for organizing and leading the preparation, on-site execution, and post-survey corrective-action process for DNV stroke certification at three hospitals: Primary Stroke Center (PSC) candidacy at Hoboken University Hospital and Bayonne University Hospital, and Thrombectomy-Capable Stroke Center (TSC) candidacy at Secaucus University Hospital. The role coordinates, rather than replaces, the clinical accountability of medical staff, nursing leaders, emergency care, and neurointerventional teams.

Essential Duties and Responsibilities — System Leadership

• Own and maintain a single system stroke program workplan, governance calendar, milestone tracker, risk register, and site-specific certification readiness dashboards.
• Lead multidisciplinary stroke steering and site workgroups; coordinate medical director/champion engagement, issue escalation, action owners, and deadlines.
• Standardize policies, order sets, workflows, documentation, transfer agreements, stroke alert activation, handoffs, and education where clinically appropriate while preserving site-specific capabilities.
• Collaborate with Quality, Patient Safety, Accreditation, ED, ICU, Nursing, Neurology, Neurosurgery/Neurointervention, Radiology, Pharmacy, EMS, Rehabilitation, Case Management, and IT/EHR.
• Provide monthly executive updates and promptly escalate patient safety, capability, staffing, and certification risks to appropriate leaders.

DNV Certification and Survey Readiness — Primary Accountability

• Maintain an up-to-date crosswalk to the current applicable DNV stroke certification requirements and associated evidence of compliance for each hospital; verify requirements against the current DNV program manuals and application materials.
• Conduct structured gap assessments and mock tracers, maintain document/evidence repositories, and validate readiness through direct observation, staff interviews, record review, and performance data.
• Prepare certification applications and survey logistics in collaboration with Accreditation leadership; manage survey agendas, document requests, interview preparation, on-site command center, and real-time issue resolution.
• Serve as the principal operational coordinator and point of contact during DNV stroke surveys, partnering with the system stroke medical director, hospital executives, and Accreditation/Regulatory leadership.
• Lead post-survey findings analysis, corrective action plans, evidence submission, effectiveness validation, and ongoing surveillance between certification cycles.
• Coordinate readiness for initial certification, surveillance, renewal, and changes in scope or capability; do not represent certification as guaranteed.

Primary Stroke Center Oversight — Hoboken and Bayonne

• Coordinate standardized acute stroke recognition, stroke-alert activation, rapid assessment, brain imaging, thrombolysis eligibility/administration, monitoring, and complication escalation pathways.
• Ensure clear protocols for large-vessel occlusion recognition, neurovascular consultation, timely transfer to a capable center when indicated, and closed-loop communication.
• Oversee competency, simulation, data capture, case review, and documentation supporting each site’s DNV PSC readiness.

Thrombectomy-Capable Stroke Center Oversight — Secaucus

• Coordinate the TSC-specific readiness plan with neurointerventional physicians, anesthesia, imaging, ED, ICU, perioperative/angiography services, and transfer/transport partners.
• Validate 24/7 coverage and response plans as required by the applicable certification standards, including contingency arrangements, staffing, equipment, and escalation.
• Oversee the end-to-end thrombectomy pathway: LVO screening, vascular imaging, specialist activation, selection/transfer, procedural readiness, post-procedure critical care, complication review, and rehabilitation transition.
• Track key thrombectomy workflow intervals and outcomes; verify case-volume, provider credentialing, and other TSC-specific criteria directly against current DNV requirements.

Clinical Quality, Data, and Performance Improvement

• Build a standardized stroke registry/abstraction process with reliable case identification, data validation, and site-level and system-level dashboards.
• Monitor stroke-alert performance, imaging and treatment times, thrombolysis and thrombectomy process measures, transfers, contraindication documentation, complications, outcomes, and guideline adherence, as applicable to each site.
• Lead timely multidisciplinary reviews of treatment delays, missed opportunities, adverse events, and deviations; develop corrective actions using PDSA or other approved improvement methods.
• Coordinate required external reporting and benchmarking, where applicable, with authorized data owners; safeguard patient privacy and data integrity.
• Present findings to stroke committees, medical executive/quality committees, and system leadership with clear action plans and sustained-effectiveness measures.

Education, Competency, and Stakeholder Engagement

• Develop an annual stroke education and competency matrix tailored to ED, ICU, inpatient nursing, physicians, radiology, pharmacy, rehabilitation, EMS, and relevant procedural teams.
• Coordinate orientation, annual education, simulation/mock stroke alerts, documentation training, and targeted remediation after identified gaps.
• Partner with EMS and referring/receiving facilities to improve pre-notification, transfer criteria, handoff quality, and regional care coordination.
• Support community stroke awareness initiatives and patient/family education in collaboration with clinical and outreach teams.

Required Multi-Site Presence and Working Expectations

• Maintain a documented, recurring on-site schedule that provides meaningful physical presence at each of the three hospitals; the schedule is adjusted according to certification phase, performance risk, and operational needs.
• Conduct in-person tracers, multidisciplinary meetings, bedside/workflow observation, staff education, and leadership rounding at each facility; remote work alone does not satisfy site oversight expectations.
• Be physically present at the hospital undergoing a DNV survey and coordinate cross-site readiness and follow-up; attend additional on-site activities for mock surveys, urgent gaps, and major stroke program events.
• Travel between campuses during normal work hours and occasionally outside routine hours as operationally necessary; not a substitute for assigned clinical stroke response coverage or 24/7 bedside staffing.

Decision Rights and Accountability

• Authorized to request program evidence, coordinate audits, convene stroke readiness meetings, assign agreed action owners through department leadership, and escalate overdue or high-risk gaps.
• Maintains the master readiness tracker and recommends policy/process revisions; clinical practice decisions, staffing approvals, credentialing, budget authority, and medical direction remain with designated accountable leaders.
• Escalates immediately any inability to meet required stroke capabilities, critical patient safety issues, or material threats to survey readiness.

Minimum Qualifications

• Current, unrestricted Registered Nurse license in New Jersey, or eligibility for NJ licensure before start date.
• Bachelor of Science in Nursing (BSN) required; MSN, MPH, MHA, or related advanced degree preferred.
• At least 5 years of progressive acute-care nursing experience, including substantial emergency, critical care, neuroscience, or stroke care exposure; at least 2 years of stroke program, quality, accreditation, or clinical program coordination experience preferred.
• Demonstrated ability to lead interdisciplinary improvement initiatives, interpret stroke performance measures, manage projects, and prepare teams for regulatory/accreditation review.
• Strong clinical documentation, EHR, data analysis, communication, presentation, and change-management skills; ability to travel reliably among all three sites.

Preferred Qualifications

• Experience with DNV stroke certification (PSC and/or TSC), stroke survey coordination, and certification evidence management.
• Stroke-focused professional certification (for example, SCRN) and NIH Stroke Scale competency, as relevant to assigned duties.
• Experience with stroke registry abstraction, Get With The Guidelines–Stroke or comparable registry, performance improvement, and endovascular stroke workflows.