RN, Nurse Navigator
Nurse Navigator Department
Full Time
Basic Purpose: Oversight of patients' progress and health needs while closing communication gaps with primary, secondary, and tertiary care providers. Identify barriers such as Social Determinants of Health that impact care delivery outcomes. Promotes collaboration across the continuum of care while keeping all stakeholders involved and up to date on patient progress or regression. Create a flexible schedule model that allows for patient centered healthcare delivery to monitor, evaluate and educate the patient and caregiver to reduce the usage of unnecessary resource usage and reduce hospitalization. Be a liaison for patients and families of different socioeconomic backgrounds and ethnicities as needs arise to achieve the most tangible outcome while transitioning across the continuum of care settings. Individuals will be responsible for the implementation and maintenance of the remote patient monitoring service line, which will include: assessment and enrollment of patients, adherence to clinical practice pathways to optimize patient outcomes, daily collection and analysis of patient data, monitoring, compliance with guidelines and program initiatives, as well as, coordinating timely and appropriate interventions. The Nurse Navigator coordinator serves as a clinical role model, educator, and liaison for the community and collaborates with providers and nursing areas to promote improved patient outcomes.
PRINCIPLE RESPONSIBILITIES
- Cooperatively develop an integrated patient centered care plan and goals with the client/family and other providers.
- Work collaboratively with team members to provide outreach and engagement with the patient.
- Advocate resource options for clients and families based on Social Determinants of Health qualifications.
- Utilization/Reporting of Remote Patient Monitoring clinical data and deviation from baseline with providers to determine if alternative treatment is warranted.
- Work closely with providers/staff members to manage day to day calls with enrolled patients involving symptom control, medication management, patient and family education, health maintenance reminders, medication refills, referral coordination, but not limited to.
- Receive and respond to telephone calls from patients. Triaging and providing medical guidance as instructed by the patient's provider. Appropriate documentation of all patient interactions according to established guidelines.
- Ensure seamless transaction of pertinent health information between the patient's care team to promote continuity of care.
- Collaborates with chronic care nursing staff, hospital multidisciplinary team members, and post-acute care setting team members to serve as a "Care Navigator" during these transitions.
- Works closely with Chronic Care Managers in the Ambulatory care setting and our current home health department.
- Serves as an advocate for the providers to ensure the most cost-effective care and resources are being utilized or arranged to meet the patient's needs based on the individual's financial capabilities and insurance plan delegation, regardless of payer source.
- Responsibility of coordinating meetings with key stakeholders and providing updates on program outcomes.
- Other duties per guidance and evolution of the program leadership determine.
Education: High school diploma or GED, associates' degree or BSN (preferred) from an accredited school of nursing and willing to pursue a higher degree or advanced certification.
Licensure: Must have a current license as an RN in the State of Mississippi or hold a multi-state license within the primary state of residency
Experience: Three to five years clinical practice experience in one or more of the following preferred areas: cardiology, pulmonology, case management, and/or nursing leadership.
Special Skills: Excellent communication skills and physician rapport required. Have the ability to navigate a variety of electronic medical record systems on the inpatient and outpatient care settings to locate patient information. Must be flexible and have a positive attitude to maintain this position. Must have critical thinking skills and be a problem solver. Experience with Microsoft and Excel is necessary for applicant and analyzing data. The ability to work independently, delegate, prioritize and multitask in a fast-paced environment. Excellent written and verbal communication skills. Individual would demonstrate exceptional customer service skills to patients/customers and internal/external providers.