Nurse Navigator

Nurse Navigator - Outpatient ClinicLocation : Coldwater, MIJob Summary:The RN Acute Care Navigator is responsible for direct patient care focusing on: CareProgression/Care Coordination, Level of Care, Length of Stay, Readmission Prevention, ValueBased Programs, Daily Transition Rounds (DTRs), Discharge Planning and compliance for theirassigned caseload to ensure appropriate patient throughput. Compliance requirements includebut are not limited to: Maintains working knowledge of Condition Code 44 Intervention, SecondIMM, MOON/Observation Status notification, Advanced Directives, Beneficiary notices, andPatient Choice. The RN Acute Care Navigator is responsible for collaborating with patient's careteam (Physicians, Nurses, Social Workers, Ancillary Services, Care Navigation Resource CenterCoordinators, Contracted Vendors, etc.) and escalating appropriately to ensure their assignedpatient receives exceptional care and avoids unnecessary delays in care progression or discharge.Duties:* All duties listed below are essential unless noted otherwise*1. Conducts in person Initial Assessment with patients/caregivers including identification ofpatient decision maker as appropriate, with goal of Initial Evaluation completion within 24hours of admission.2. Develops Discharge Plan (with associated contingency plan) within 24 hours of admission;updates, as appropriate.3. Assesses patients to determine ability for self-care and to identify those most at risk for post dischargeadverse health consequences without intensive discharge planning. Provides adischarge planning evaluation to those patients identified as at risk and upon the request ofthe patient, key stakeholders, members of the interdisciplinary team or the physician.4. Conducts a comprehensive assessment of the patient's physical, psychosocial, spiritual,environmental, and caregiver status to identify post-hospitalization needs. Documents allfindings in the EMR. Identifies patients most at risk for readmission without intensivedischarge planning through information gathered on the admission nursing database,electronic medical record (EMR) predictive analytics tools, and proactive case finding.5. Completes Readmission Assessment on readmitted patients.6. Shares Readmission Risk score daily during DTRs; collaborates with interdisciplinary team toidentify high risk patients whose risk score may not have indicated appropriately;implements interventions according to risk score.7. Identifies transitional care barriers and collaborates in comprehensive, patient-centered careplan development. Reassesses patients and revises the plan as applicable.8. Implements Discharge Plan; inclusive of Discharge Plan communication and confirmation andincludes patients/caregivers in Discharge Plan development to gain participation, agreement,and accountability.9. Stratifies assigned patients by Clinical, Financial, and Psychosocial risk factors and submitsfollow-up referrals, as appropriate.10. Consults Social Work for complex discharges and psychosocial/SDOH needs.11. Develops, documents, and communicates Care Coordination Plan, updates as appropriate.12. Collaborates with UM team, as appropriate and applies clinical understanding of medicalnecessity criteria, patient status and discharge criteria and assists UM team by relayingpotential changes in medical necessity/appropriate patient status/LOC.13. Reviews necessary patient information, including lab and other test results and progressnotes in patient health record daily.14. Collaborates and actively engages patients and key stakeholders throughout interdisciplinaryprogression and coordination of care along with the discharge planning process to ensure apatient-centered plan and document accordingly.15. Partners with physicians as appropriate for care progression, care coordination andappropriate length of stay and collaborates with other key team members to managetransitional care activities and communicate vital information.16. Actively participates in DTRs and facilitates discussion of progression and discharge needs.17. Establishes initial Estimated Discharge Date (EDD), updates, as appropriate.18. Discusses EDD with patient and/or caregiver(s).p. 319. Validates EDD with care team (inclusive of Attending Physician).20. Validates Discharge Plan with Interdisciplinary Team (Physician, Nursing, etc.); updates asneeded.21. Escalates issues to appropriate level of Care Navigation leadership and coordinatesmitigation activities in a timely manner as needed.22. Provides supplementing patient-centered education to patients and key stakeholdersregarding disease processes, medications, treatments, diet, and nutrition, expectedsymptoms and when/how to seek additional help. Utilizes motivational interviewing andteach back techniques as appropriate.23. Coordinates patient access to necessary services, including community and public healthresources. Assists patients/caregiver in selecting a post-acute care provider by sharing dataon quality measures and resource use measures that are relevant and applicable to thepatient's goals of care and treatment preferences.24. Ensures assigned patients have an identified Primary Care Physician (PCP)/Specialist andfollow-up appointment (or appropriate follow-up plan) scheduled prior to discharge; if PCPnot identified, exhausts all efforts to assign.25. Ensures effective communication through the continuum to support ongoing progresstoward identified outcomes.26. Communicates necessary medical information to appropriate facilities, agencies oroutpatient services for follow-up or ancillary care, including all essential medical information.27. Serves as a supportive resource regarding payor information; educates interdisciplinary teamand patients/caregivers regarding payor requirements and/or barriers.28. Works in partnership with acute and ambulatory care team to follow patient through carecontinuum and ensures thorough hand-off to ambulatory Care Navigators/Care Managers orpost-acute caregivers. Serves as an essential link for patients without a primary physician.29. Ensures timely delivery of second IMM notification, as appropriate.30. Maintains positive working relationships with all internal and external customers.31. Attends applicable conferences, trainings, and meetings. Participate in quality improvementand strategic initiatives.32. Completes special projects and other duties, as assigned.Required Qualifications:Education: Must have either a BSN, or 5 years of applicable nursing experience.Skills: Must have a history of positive rapport with patients, families, physicians, andinterdisciplinary team members. Relevant experience working with diverse populations. Must have exceptional problem-solving, critical thinking, organizational, interpersonal, and written/verbal communication skills. Ability to work in a self-directed environment with attention to detail and follow-through. Must be able to function effectively in a critical care environment. Able to establish priorities and respond to inquiries. Critical thinking skills. Works as a team player with the interdisciplinary team to reach care goals. Ability to manage multiple tasks and prioritize levels of importance. Ability to manage assignments with minimal supervision, work as a part of an interdisciplinary team, and focus on optimal patient and department outcomes. Performs duties in a manner to promote quality patient care and customer service/satisfaction, while promoting safety, cost efficiency, and a commitment to Insight principles. Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization. Ability to work with people of all social, economic, and cultural backgrounds; be flexible, open-minded, and adaptable to change.Years of Experience: 5 years of applicable nursing experienceLicense: A current, active, and unrestricted licensure as a Registered Nurse in the state of practice is required.Certification: N/APreferred Qualifications:Education: MSN or higher degreeSkills: Applicable experience in patient advocacy, care management, and knowledge of hospitaland community resources.Years of Experience: Case management or similar experienceLicense: RNCertification: Specialty certification in care management (CCM, RN-BC, ACM, or similar).Physical Requirements:Personal Protective Equipment: Must adhere to PPE requirements of the work setting.Physical Demands: Must be able to stand for long periods of time. Must be able to work at a rapid pace for long periods of time.