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.
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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.
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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.
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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.
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Serve as an essential link between patients and all other care providers.
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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.
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Develop patient education program and tools.
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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.
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Identify patients with no PCP and provide the patient’s options based upon their preference and their payor source.
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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.
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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.
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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.
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Collect data, track outcomes and support strategic planning process to reduce hospital readmissions.
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Adhere to productivity benchmarks
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Responsible for outreach efforts to establish and maintain working relationships with key customers (physicians, office staff, diagnostic staff, nurses, etc)
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Acts as a client advocate in securing education, health care, counseling, transportation, medication and other needed services.
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Assess client dynamically, develop case management plan and work with client to meet goals of plan.
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Accurately identify and prioritize at risk community population.
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Demonstrated ability to use teaching, learning, and counseling skills
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Assumes leadership roles to help the patient population served.
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Serve as preceptor/evaluator for various disciplines.
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Coordinate primary and secondary prevention opportunities that promote early identification and intervention for various populations.
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Lead and /or participate in interdisciplinary team meetings.
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Utilize advanced assessment skills to work autonomously with community agencies, hospitals, health care providers, and social service agencies.
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Abide by HMH Legal Compliance Code of Conduct.
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Maintains patient confidentiality and appropriate handling of PHI.
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Maintains a safe work environment and reports safety concerns appropriately.
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Performs all other related duties as assigned.
LATITUDE, CONTACTS/INTERACTIONS
All positions of Huntsville Memorial Hospital are part of an interdisciplinary team, and as such, participate in the care and service delivery process through effective interaction with other team members. Primarily interacts with hospital staff, medical staff, patients, and visitors.
Requirements
Education: Graduate of a school of professional nursing.
Experience: RN with two years of Acute Care Hospital Case Management/Patient Navigation experienced preferred. Will consider LVN with Acute Care Case Management/Care Coordination/ Patient Education experience. Previous experience with CHF, COPD, Pneumonia, Joint Replacement, New Diabetic patients and mitigating Readmissions is preferred.
Licensure/Certification: Current licensure as a Registered Nurse in the state of Texas, or immediately eligible.
Required Skills: Must have strong analytical, data management, organizational and time management skills. Knowledge of teaching/learning theories and skills in developing and providing individual and group education/training. Knowledge of community resources. Skilled in the assessment of clients with complex social, mental and health problems. Skilled in creating interpersonal relationships, interacting with all levels of education, social differences, and various ethnicities and cultures.
Work Schedule- Saturday and Sunday
Frequent: sitting, standing, walking, & reaching.
Occasional: lifting, carrying, bending, & squatting.
Visual and hearing acuity required. Work is mostly inside, with good ventilation and comfortable temperature, as well as outside in the community and could require some driving.
Possible exposure to: toxic/caustic chemicals or detergents, communicable diseases, blood borne pathogens.
Benefits
- Health Care Plan (Medical, Dental & Vision)
- Retirement Plan (401k, IRA)
- Life Insurance (Basic, Voluntary & AD&D)
- Paid Time Off
- Short Term & Long Term Disability
- Training & Development
- Wellness Resources
