Nurse Navigator- RN BSN Required (Rutland) at / RN Jobs

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Nurse Navigator- RN BSN Required (Rutland)

at in Rutland

POSITION SUMMARY: The Patient Navigator coordinates care and services for a select group of patients/families to guide them through the health care experience. This coordination of care is accomplished through a collaborative process working with the patient/family and the interdisciplinary team (IDT). The Patient Navigator will function as the primary architect in the development of an optimum discharge date, and will follow-up post discharge to provide continuity of care.
RESPONSIBILITIES/ACCOUNTABILITIES:
1. Interdisciplinary Collaboration:
1.1. Review assessment data collected by Clinical Admission Directors (CADs) and Interdisciplinary Team (IDT) members for short stay admissions.
1.2. Supplement data collection through interviews with patient/family and as applicable, review of hospital records and/or communication with hospital personnel.
1.3. Coordinate care, treatment and communication among the IDT to meet patient goal
1.4. Collaborate with the patient and IDT to develop, implement and evaluate a discharge plan that addresses patient/family needs;
1.5. Collaborate with IDT to ensure patient's length of stay is appropriate to the attainment of patient goals;
1.6. Attend Utilization Management Review meetings
2. Provide care management and oversight services
2.1. Meet with patient and family to discuss Medicare/insurance coverage, plan of care, and discharge plan
2.2. Monitor treatment plan and ongoing care to evaluate effectiveness of interventions, medical necessity, and continuation of care
2.3. Act as benefits interpreter in areas of co-pays, supplemental and eligibility issues
2.4. Ensure pre-discharge teaching sessions are conducted with patient and family. Such sessions may include but are not limited to:
2.4.1. Chronic disease self-management including self-monitoring, care to manage symptoms and actions to address changes;
2.4.2. Medication reconciliation and education of ongoing medication administration (oral, injectable, parenteral/enteral infusion, etc.)
2.4.3. Durable medical equipment reconciliation and management of existing equipment and new equipment
2.4.4. Review of the discharge packet and discharge instructions with patient/family prior to discharge;
2.5. Collaborate with Social Services to identify community care providers (e.g. home health care, infusion services, specialty wound care, DME, transportation, etc.);
3. Patient/Family Support Post-Discharge
3.1. Conduct follow-up calls to patients and families to ensure that resources meet their needs and to identify additional needs;
3.2. Coordinate care among community providers;
3.3. Coordinate appointments with providers to ensure timely delivery of diagnostic and treatment services;
3.4. Identify gaps in resources offered and work within the community to bridge those gaps;
3.5. Ensure that appropriate medical records are available for scheduled appointments and insurance purposes;
4. Quality Improvement
4.1. Track, trend and report:
4.1.1. Patient length of stay;
4.1.2. Rehospitalization rate;
4.1.3. Patient/family satisfaction;
4.1.4. Services and clinical outcomes of post-SNF providers.
5. Performs other related duties as required.
SPECIFIC EDUCATIONAL/VOCATIONAL REQUIREMENTS:
1. Must be a graduate of an accredited school of nursing, college or university with a current registered nurse licensure by the State Board of Nursing.
2. A minimum of five years full-time or equivalent clinical experience is required and a minimum of two years of clinical experience in long-term care nursing is preferred.
3. BSN required. Location: Rutland
Compensation: based on experience
Principals only. Recruiters, please don't contact this job poster.
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