Senior Registered Nurse Navigator Population Health
Company: Christus Health
Posted on: October 12, 2021
The RN Navigator is a member of the patient's care team and acts
as a patient advocate providing proactive outreach to patients with
chronic illness for the duration of their chronic care condition.
The RN Navigator facilitates communication and coordinates care
with physicians, the providers' clinic, hospital facilities,
family, caregivers and other community healthcare providers and
implements creative to meet members/ healthcare needs without
compromising quality of outcomes. The RN Navigator will identify
and enroll patients with chronic health conditions and/or refer to
other programs as appropriate. The RN Navigator will support
transitions of care as assigned and/or chronic condition support or
health/wellness programs for the assigned population.
The position responsibilities also include supporting health
risk reduction through goal setting, behavioral change, patient
education, and identification of social determinants with
appropriate community referrals. In addition, the RN Navigator
focuses on reducing preventable admissions, re-admissions, and
preventable ED visits by supporting discharge planning to the next
level of care and educating patients regarding the appropriate
setting for care. The RN Navigator connects the patient to health
care providers and community resources to ensure ongoing quality of
care. The nurse also promotes optimal person-centered care that
supports and empowers individuals, respects individual choices and
meets health care needs of patients. Receives and evaluates HH
485 form (Plan of Care) based on Medical Necessity guidelines and
Homebound Status requirements. Facilitates Case Conferences
with HH Agency for evaluation of patient progress toward goals and
discharge plan. Ensures HH agency is addressing the problem
list and providing appropriate follow up for patient
needs. Based on CMS or other payer guidelines, patient
assessment, and case conferences, makes recommendation to PCP re:
HH re-certification or discharge from service.Creates positive
relationships with HH agencies as well as Primary Care Clinicians
and Office Staff. Ensures smooth transition of care along the
continuum. Facilitates communication between HH agency and PCP
practice as necessary to ensure patient's needs are
addressed. Stays abreast of current CMS and other payer
guidelines for HH services. Demonstrates expertise in
navigating electronic medical record and other care management
applications. Utilizes MCG Guidelines for Home Care to
optimize the type, frequency, and duration of care. Monitors
key measures of program success and provides feedback re:
opportunities to improve.
- Facilitates communication and provides care coordination along
the continuum of care including inpatient care team as well as the
physician and community care team.
- Ensures appropriate management/stabilization of chronic medical
conditions to prevent readmission and promote optimal
- Ability for timely completion of initial assessment and plan of
care including the patient, their support system, physician and
other health team members to address condition, social
determinants, and promote patient knowledge and behavior
- Develops relationships with and facilitates referrals to
community resources including Skilled Nursing Facility (SNF),
Rehab, Long Term Acute Care (LTAC), Home Health, Hospice,
Palliative Care, Transportation, Medication Asst., DME, and other
- Completes activities pertaining to achieving and maintaining
quality measures related to payer contracts as indicated.
- Demonstrates the confidence, drive and ability to face and
overcome obstacles to achieve organizational goals.
- Exhibits behaviors and actions which create a high level of
patient satisfaction, contributes to positive patient relations and
reflects respect for a patient's rights, needs and
- Perform ongoing essential Care Coordination activities of
assessment, barrier and strengths identification, planning,
implementation, coordination, monitoring, and evaluation of
patients. Implements practice/action to overcome barriers to
- Documents all communication and responses to care plan
interventions as directed; active cases should have appropriate
documentation depending on the severity of medical condition, risk
score, social determinant needs.
- Meets all general requirements, annual competencies, and
maintains knowledge of all regulatory Federal, State, Local
regulations and VBP contract requirements.
- Demonstrates effective communication and human relations skills
that promote harmony and teamwork.
- Presents behaviors and actions that maintain the hospital's
credibility, integrity, and positive image.
- Demonstrates behaviors and actions that support the mission,
goals, and operations of the CHRISTUS Health System and which
contribute to continuous quality improvement.
- Maintains a positive attitude and exhibits flexibility in work
hours, duties, and job requirements; willingness to perform other
duties as assigned.
- Identifies and outreaches to eligible patients in hospital
setting or per phone outreach.
- Works collaboratively with team members in discharge
- Coaches patients and caregivers toward self-management.
- Performs outreach either home visit or telephonic between 24-72
hours post discharge
- Confirm post-acute services are being provided
- Confirms appointment has been made with PCP within 7-14 days
- Performs medication reconciliation, updates EHR, and
communicates with provider.
- Performs follow up calls as per program.
- Completes required documentation and tracking of
- Makes appropriate referrals for medication assistance,
transportation, Home Health, DME, and other medical and non-medical
- Ensures discharge summary is included in the EHR and reviews
discharge instructions with patient and/or caregiver.
- Provide education re: condition, medication and appropriate
setting for care.
- Identify target diagnoses' with preventable
- Completes effective project-focused phone calls to patients at
specified time interval based on regional population analysis,
i.e., (5-7 days, 10-14 days, 23-30 days).
- During all outreaches focus on medication
reconciliation/self-management; use of personal health record.
Follow up with PCP and Specialists; and review of indicators that
patient's condition is worsening and how to respond.
- BSN Preferred
- 3-5 years acute care/clinical experience; 2-3 years managed
care and/or care management experience; experience with high level
communication; ability to lead interdisciplinary teams; ability to
serve as a patient advocate
- Texas RN License Required
Keywords: Christus Health, Irving , Senior Registered Nurse Navigator Population Health, Other , Irving, Texas
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