Registered Nurse Navigator Population Health Senior
Company: Christus Health
Location: Irving
Posted on: January 23, 2023
Job Description:
Description
Summary: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, readmissions, 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. The Nurse Navigator will
monitor patients throughout the episode of care making
recommendations for ongoing services to providers and home health
agencies based on Medicare guidelines.In addition, the RN Navigator
focuses on reducing preventable admissions, readmissions, 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
recertification 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 outcomes
- 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
change
- 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
community resources
- 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
confidentiality
- 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
care.
- 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 assignedRequirements:
- BSN Preferred
- 3-5 years acute care/clinical experience; 2-3 years managed
care and/or care management experience; 1-2 years of Home Health
experience; experience with high level communication; ability to
lead interdisciplinary teams; ability to serve as a patient
advocate
- Texas RN License RequiredWork Type: Full Time
Required
Keywords: Christus Health, Irving , Registered Nurse Navigator Population Health Senior, Other , Irving, Texas
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