Transitional Care Navigator - Care Continuum Community Health

Job Description
POSITION SUMMARY:
To be fully engaged in providing Quality/No Harm, Customer Experience, and Stewardship the Transitional Care Navigator position is responsible for performing care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the Care Continuum.
Transitional Care Navigators work within a defined patient population to promote the achievement of optimal clinical and resource outcomes. Transitional Care Navigators utilize independent clinical judgment and works collaboratively with the interdisciplinary team to promote quality of care through collaboration with all team members, patients, families and significant support personnel.
Transitional Care Navigator performs overall coordination of care for identified members via telephonically or on-site such as at hospitals, in-home, or various placements for discharge planning.
The Transitional Care Navigator plans effectively to meet patient needs during their hospital stay regarding processing them through the system and managing the length of stay, promoting efficient utilization of resources, and plans for a safe discharge continually evaluating and updating patient status. Specific functions within this role include:
PRIMARY ACCOUNTABILITIES:
Quality/No Harm:

1. Facilitation of patient's transitional plan in collaboration with the physician, nursing and interdisciplinary team.
2. Facilitation of the collaborative management of patient care across the continuum, intervening as necessary to remove and escalate barriers to timely and efficient care delivery.
3. Application of process improvement methodologies in evaluating outcomes of care.
4. Identifies at-risk populations using approved screening tool and follows established referral processes for patients.
5. Promotes professional practice through collegial support and interactions.
6. Practices autonomously, consistent with evidence-based standards.
7. Using identified reports, works collaboratively with Care Transitions team to identify high risk patients and assure safe transition to the next level of care to prevent readmissions.

Qualifications:
QUALIFICATIONS REQUIRED:

• Current valid license to practice as a Registered Nurse in the State of Florida
• Bachelor of Science Nursing required or Associate Degree with 7-10 years of clinical experience.
• Three or more years' strong clinical experience in clinical practice area
• Excellent interpersonal communication and negotiation skills.
• Community education and public speaking experience preferred
• Knowledge of managed care concepts, health promotion/disease management strategies,
  and trans theoretical model Strong analytical, data management and PC skills.
• Current working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement preferred.
• Understanding of pre-acute and post-acute venues of care and post-acute community resources.
• Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.
• Ability to work independently and exercise sound judgment in interactions with physicians, patients and their families.
• Performs duties in a manner to promote quality patient care and customer service/satisfaction, while promoting safety, cost efficiency, and a commitment to the process improvement process.
• Excellent writing and presentation skills.