Registered Nurse Navigator Population Health Senior
Location: Tyler, Texas
Internal Number: 12231800
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.
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 assigned
Identifies and outreaches to eligible patients in hospital setting or per phone outreach.
Works collaboratively with team members in discharge process
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 appt has been made with PCP within 7-14 days post-discharge
Performs medication reconciliation, updates EHR, and communicates with provider
Performs follow up calls as per program
Completes required documentation and tracking of data
Makes appropriate referrals for medication assistance, transportation, Home Health, DME, and other medical and non-medical needs
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 readmissions
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.
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
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.