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.
Facilitates communication and provides care coordination along the continuum of care including inpatient care team as well as the physician and community care teamEnsures appropriate management/stabilization of chronic medical conditions to prevent readmission and promote optimal outcomesAbility 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 changeDevelops 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 resourcesCompletes activities pertaining to achieving and maintaining quality measures related to payer contracts as indicatedDemonstrates the confidence, drive and ability to face and overcome obstacles to achieve organizational goalsExhibits 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 confidentialityPerform 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 teamworkPresents behaviors and actions that maintain the hospital's credibility, integrity, and positive imageDemonstrates behaviors and actions that support the mission, goals, and operations of the CHRISTUS Health System and which contribute to continuous quality improvementMaintains a positive attitude and exhibits flexibility in work hours, duties, and job requirements; willingness to perform other duties as assignedIdentifies and outreaches to eligible patients in hospital setting or per phone outreach. Works collaboratively with team members in discharge processCoaches patients and caregivers toward self-managementPerforms 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-dischargePerforms medication reconciliation, updates EHR, and communicates with providerPerforms follow up calls as per programCompletes required documentation and tracking of dataMakes appropriate referrals for medication assistance, transportation, Home Health, DME, and other medical and non-medical needsEnsures 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 careIdentify target diagnoses' with preventable readmissionsCompletes 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.
BSN Preferred3-5 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 advocateTexas RN License Required