Nurse Admin Home Health

The RN Navigator in Population Health is responsible for coordinating and managing patient care across the healthcare continuum. This role focuses on improving health outcomes for populations by implementing evidence-based practices, promoting preventive care, and ensuring patients receive appropriate and timely interventions. The RN Navigator will work collaboratively with ACO and CIN Network providers, patients, and their families across CHRISTUS Health ministries to develop and implement individualized care plans. The RN Navigator will manage the length of service, promote efficient utilization of resources, and ensure that a well-organized and safe plan of care is established for every patient. Care Coordination of Complex/Chronic conditions: Manages and coordinates care for patients with chronic conditions, complex medical needs, and assists with Discharge Planning: Helps plan and coordinate the discharge process for members leaving hospitals or long-term care facilities, ensuring a smooth transition to home or another care setting. Care Coordination - Transitions of Care: Outreach to patients that qualify for Transitions of Care (IP Discharge) and ensure they understand their medications, educate patients on managing their conditions and knowing when to seek help, stressing the importance of scheduling and attending follow up appointments, and teaching them to recognize the signs that their condition might be worsening. Patient Assessment: Conduct comprehensive assessments to identify patient needs, barriers to care, and social determinants of health. Care Planning: Develop and implement individualized care plans based on patient assessments, clinical guidelines, and patient preferences. Focuses on reducing preventable admissions, readmissions, and preventable ED visits by supporting discharge planning to the next level of care and educating patients about the appropriate setting for care. Serve as an advocate for patients or clients, helping them to navigate the healthcare system, understand their treatment options, and access the services they require. Collaboration: Work closely with healthcare providers, social workers, and community resources to ensure a holistic approach to patient care. Track and communicate to PCPs and specialty care providers any significant changes to members' concerns, along with any updates on members' status. Maintain accurate and timely documentation of patient interactions, care plans, and outcomes in the electronic health record (EHR) system. Quality Improvement: Participate in quality improvement initiatives to enhance patient care and population health outcomes. Compliance: Ensure compliance with all regulatory requirements, organizational policies, and best practices in case management. Bachelor's Degree in Nursing preferred 2 years of case management experience required ~ Experience working in a primary care value-based care organization is required ~ Knowledge of population health management principles is required Licenses, Registrations, or Certifications RN license in the state of employment or compact is required Nursing Case Management Certification (CMGT-BC) by ANCC Full Time