Job Description
Under supervision of the Director of Case Management, the Patient RN Navigator, utilizes the nursing process in assessing, planning, implementing, coordinating, delivering and evaluating population based, specialized nursing. Services are provided to individuals with health needs ranging from simple to complex and are focused on the promotion of optimum wellness and disease prevention. Collaboration with state, local, public, and private agencies to ensure services to the patients served. The Patient RN Navigator should be an individual with a strong initiative in instituting, monitoring and evaluating projects. Ability to practice in an autonomous setting and provide guidance to patients and their families. The Patient Navigator RN serves as a contact for patient and caregivers to provide resources and assistance with accessing clinical and supportive care services. The Patient Navigator-RN facilitates patient/family education regarding their disease process and strategies to decrease hospital readmission. The RN will facilitate patient appointments, including but not limited to diagnostic imaging, appointments for follow-up post hospitalization with their PCP and with specialty physicians as indicated. ESSENTIAL JOB FUNCTIONS Every effort has been made to make this job description as complete as possible. However, it in no way states or implies that these are the only duties the incumbent will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is a logical assignment to the position. Assist patients/families in understanding their diagnosis, treatment options, and the resources available, including educating eligible patients about appropriate strategies to improve quality of life and reduce hospital admissions. Facilitates post hospital follow-up appointments with physicians, dieticians, social workers, other healthcare and community resource appointments. Accountable for developing, facilitating services and partnering with community resources to address the needs of the patient when possible. Collaborates with other community agencies to identify potential resources for resolving client’s health, psychosocial, or financial problems that are impacting their health care and hospitalizations. Serve as an essential link between patients and all other care providers. Coordinate multidisciplinary planning conferences as needed, develop patient summaries for use by the care team and document recommendations made utilizing standardized care protocols in accordance with nationally recognized care guidelines. Develop patient education program and tools. Follow patients with high risk readmission diagnoses and/or patients with frequent hospital admissions throughout the care continuum including inpatient and post hospitalization and collaborate with patient care management resources. Identify patients with no PCP and provide the patient’s options based upon their preference and their payor source. Identified high risk patient populations will be called within 48- 72 hours post hospitalization to identify any barriers or concerns related to their care post hospital visit and to determine if intervention is needed. Patients with frequent hospitalizations will receive additional follow-up phone call to remind of their physician’s appointment and then after the appointment to determine the outcome of their physician visit. The designated caregiver of patient’s identified as high risk for hospitalization and/or readmission will be contacted with the patient’s authorization to update them regarding care needs/challenges that they may be able to assist with to reduce the likelihood of the patient’s hospitalization and/or readmission. Collect data, track outcomes and support strategic planning process to reduce hospital readmissions. Adhere to productivity benchmarks Responsible for outreach efforts to establish and maintain working relationships with key customers (physicians, office staff, diagnostic staff, nurses, etc) Acts as a client advocate in securing education, health care, counseling, transportation, medication and other needed services. Assess client dynamically, develop case management plan and work with client to meet goals of plan. Accurately identify and prioritize at risk community population. Demonstrated ability to use teaching, learning, and counseling skills Assumes leadership roles to help the patient population served. Serve as preceptor/evaluator for various disciplines. Coordinate primary and secondary prevention opportunities that promote early identification and intervention for various populations. Lead and /or participate in interdisciplinary team me