Aco Nurse Navigator, Healthcare Delivery Transformation

The GW Medical Faculty Associates (MFA) was incorporated in July 2000 as a not-for-profit, physician-led practice group. The organization functioned as an independent organization in support of The George Washington University School of Medicine and Sciences as a multi-specialty physician practice group. The GW MFA has grown to become the largest independent academic physician practice in the Washington, DC metro region with 375 physicians and 100 APP providers. In 2018, the MFA bylaws were revised to allow The George Washington University to serve as the sole corporate member while the MFA retained independent 501c3 status. The purpose of the change was to ensure alignment between the MFA and The George Washington University.
MFA physicians provide comprehensive patient care, offering one practice for the whole person with 52 medical and surgical specialties. As members of the GW School of Medicine and Health Sciences faculty, MFA providers are teachers and mentors for medical students, residents, fellows, and researchers preserving the rich tradition of academics, research, and healing. In addition to maintaining a closely integrated alliance with The George Washington University and The George Washington University Hospital (GWUH) which is separately owned and operated by Universal Health Services (UHS), the GW MFA has active referring relationships with 12 area hospitals.
The GW MFA's leading healthcare presence in the DC metro region is complemented by a network of community-based practices in DC, Maryland, and Virginia. Given its geographic location in central NW Washington, DC, and proximity to more than 175 resident embassies, the MFA continues to evolve its international clinical outreach.
Position Summary
The Nurse Navigator provides patient-centered care management services for patients with multiple chronic conditions, in conjunction with the patient's care team. The Nurse Navigator will a) support coordinated care transitions, b) provide nurse navigation and chronic care management support for identified high-risk patients, c) participate in quality improvement initiatives and proactive panel management, e) provide patient and family education on disease monitoring and treatment plans. This individual performs duties telephonically and in person to engage patients with their care team and provide coordinated care.
Essential Duties and Responsibilities
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Other duties may be assigned.
This position reports to the Sr. Dir. Of Quality and Safety at the Medical Faculty Associates (MFA). Primary duties include, but are not limited to:
Transition to Care Management

• Regularly monitor inpatient and ED discharges for all Medicare patients.
• Contact patients within 2 days of inpatient discharge for care coordination, such as obtaining required specialty and PCP appointments within the required timeline, social worker, home care set-up, and medication reconciliation, and ensure all summary of care documentation is available in the chart at pending visits.
• Contact patients within 1 to 2 days of ED discharge for clinically appropriate follow-up.
• Provide appropriate clinical support, counseling, and education. Alerts provider to urgent situations that cannot wait until scheduled follow-up.
• Review the inverse TCM reports to identify the opportunities with the TCM visits.

High-Risk Patient Population Management:

• Coordinate care management services for high-risk patient populations identified by claims data (frequent admissions/ED visits).
• Work with the Primary Care Provider, Patient Navigator, and other members of the patient's care team focusing on reducing readmissions and addressing chronic disease conditions and social/environmental concerns that may lead to repeat hospital stays/visits.
• Use care gap info to arrange appropriate follow-up prior to clinical deterioration.
• Review readmission rates quarterly to see the trending with outreach, appointment completion, and impact on the readmission rates.

Clinical Quality Management:

• Identify and interpret care gap info to ensure that quality measures are being met, costs are being managed, and clinical processes support quality measures while working on the patient's care.
• Assist with the development of a system for electronic and automatic patient reminders needed for care management.
• Participate in quality improvement activities under the direction of the Sr. Director of Quality and Safety to optimize patient outcomes.

Patient and Family Education

• Provide clinical support, counseling, and education. Alerts provider to urgent situations that cannot wait until scheduled follow-up through TigerConnect and Epic.
• Provide self-management education and support in chronic care management.
• Maintain educational materials and references for patients and families (aspirational)

Minimum Qualifications
Education

• A Bachelor's degree or higher in Nursing, or an equivalent combination of training and experience.

Licensure

• A current, valid, and unrestricted D.C. license as a Registered Nurse.

Experience

• A minimum of 2 years of RN experience in a clinical setting, including 1 or more years of nurse care management experience.
• Proficiency in electronic health records.
• Proficiency in Microsoft Office Suite applications, specifically Word and Excel.

Physical Requirements

• Sit, walk, reach, bend, or twist for long periods of time in a clinical setting.
• Must be able to lift, carry, push, or pull up to 100 lbs. as part of the role.
• Regularly exposed to healthcare settings that may require personal protective equipment.
• Requires manual dexterity to operate a computer keyboard, calculator, copier machine, and other equipment.