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Registered Nurse Navigator Population Health Senior - Population Health Admin
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- Job 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 will support transitions of care as assigned and/or chronic condition support or health/wellness programs for the assigned population.
- 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.
- Responsibilities: 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.
- Based on CMS or other payer guidelines, patient assessment, and case conferences, makes recommendation to PCP re: HH recertification or discharge from service.
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