Rn Navigator - Community Care Management

Overview

The RN Navigator functions on a multidisciplinary team to facilitate, coordinate, and bridge the gap between outpatient management and hospital- acute management. The RN navigator assesses patient risk and determines appropriate interventions based on patient needs. The RN navigator coordinates care with the multidisciplinary team across the continuum of care. The RN navigator is responsible for ensuring all patients receive quality and comprehensive services. The RN Navigator will serve as the primary contact for their identified patient population. The RN navigator will serve as a clinical resource with expertise in the care and management of their patient population and functions across the healthcare continuum to facilitate the best possible clinical outcomes for optimal wellness in the most appropriate resource.

Responsibilities

Evaluation and Assessment
* Conducts evaluations of attributed patients identified for possible surgery and provide clinical Care Management risk attribution.

* Completes psychosocial assessments to guide the development of care plans with the identified patient to lower risk threshold for care delivery.

Collaboration
* Collaborates with surgeons, care team and external providers.

Care Plan and Documentation
* Develops care plans with the identified patient to lower risk threshold for care delivery.

* Facilitates the progression of care by advancing the care plan identification of outcomes, implementation plan and sets goals that are measurable, realistic, and individualized.

* Ensures appropriate documentation in the electronic medical record.

Care Coordination
* Coordinates care delivery with service lines and provider groups across the organization and the region.

* Manages costs and utilization of hospital services in order to manage financial obligations for the patient, the family, and the hospital.

* Utilizes hospital, community and national resources to maintain and enhance knowledge and expertise of the case management team.

Community Care Management
* Supports patient after discharge from post-acute to ensure appropriate compliance and support occurs to avoid readmission or poor quality outcomes.

* Monitors outcomes and develops process change to improve care.

* Assists patients with finding the highest quality, low cost, post-discharge care.

Compliance/Safety
* Responsible for reporting any safety-related incident in a timely fashion through the Midas/RDE tool; attends all safety-related training programs; performs work in a safe manner; monitors work environment for possible safety issues and ensures others are also performing work in a safe manner.

* Stays current and complies with state and federal regulations/statutes and company policies that impact the employee's area of responsibility.

* If required for the position, ensures all certifications and/or licenses are up-to-date and valid prior to expiration dates.

* Completes all company mandatory modules and required job-specific training in the specified time frame.

Qualifications

Education
Bachelor’s Degree in Nursing- Any RN hired on or after July 1, 2016 must graduate from a BSN program within 6 years from the date of hire into a RN position. Any RN hired before July 1, 2016 is not mandated to obtain a BSN but is encouraged to do so.

Master's Degree in Nursing- Preferred

Certification & Licensures
Active, unrestricted, Arizona RN License or valid, participating compact license- Required

BLS (American Heart Assoc.)- Required

Fingerprint Clearance Card application number- Required upon hire

Fingerprint Clearance Card- Required within 90 days of hire

National Certification in relevant specialty- Preferred

Experience
Two years as a Registered Nurse- Required

Two years experience working with specific specialty patients- Preferred

Experience and working knowledge of Care Management concepts for specific chronic diseases as pertains to the specific navigator role- Preferred

Healthcare is a rapidly changing environment and technology is integrated into almost all aspects of patient care. Computers and other electronic devices are utilized across the organization and throughout each department. Colleagues must have an understanding of computers, and competence in using computers and basic software programs.