Temp to Perm Care Transition Navigator - Days

Washington Hospital•Fremont, CA

91d•$95 - $128•Hybrid

About The Position

Act as a “Coach” in the Transitional Care Program, ensuring patients continue to receive coordinated, quality care post-discharge and to reduce unnecessary admissions and readmissions to the hospital. In addition to performing the essential functions listed below, may also be assigned other duties as required.

Requirements

Graduate of an accredited school of nursing with a current California RN license required
Bachelor’s degree, or a combination of clinical education and/or experience required
Current AHA BLS certification required
Current driver’s license, vehicle insurance and access to a dependable vehicle or public transportation required
Experience with Microsoft Office (Word, PowerPoint, Excel, etc.) and/or Google Suite (Docs, Sheets, etc.) required
Must be willing to work weekends
Must have effective communication skills to interact with patient and family.

Nice To Haves

Experience in health coaching, motivational interviewing desired
Experience and comfort with home visits preferred
Master’s Degree in Health Care Administration or Nursing, or in a work-related field from an accredited college or university preferred
Two to three years of experience in transitional care preferred

Responsibilities

Collaborates with outpatient providers, case management, and post-acute care providers to ensure optimal delivery of transitional needs
Prioritizes referrals and activities according to intensity, need, and required follow-up
Documents all activity related to patient care in electronic medical record system, including visits, orders, contact with additional resources, conversations with patients or other agencies, as well as any other information related to patient care and well-being
Evaluates aspects of each patient’s condition, diagnoses, medications, and support systems to formulate an individualized plan which will lead to successful outcomes in medication(self)-management, use of a dynamic patient-centered record, appropriate primary care and specialist follow-up, and knowledge of red flags
Visits patients in their homes and other ambulatory settings (i.e. skilled nursing facilities, post-acute rehabs, etc) as part of the Transitional Care Program
Provide education on chronic illnesses to encompass: disease process, medication administration to include side effects management, and proper use of prescribed devices and/or medical equipment
The individual identifies and resolves problems in a timely manner and excels at locating, retrieving, evaluating and using information skillfully
Demonstrates client-centered focus
Demonstrates flexibility without over reliance on protocols
The individual prioritizes and plans work activities, uses time efficiently, and develops realistic action plans
Achieves timely and efficient care coordination through a multidisciplinary effort with members of the health care team.
Interacts with physicians, and other providers, patients and families to coordinate services for patients’ post-hospital care in a timely manner and follow-up to ensure appropriate care is received
Aligns teaching plan with those developed by other disciplines as a way to ensure care coordination
Coordinates care in a manner that produces the best patient outcome in an effective and efficient manner
Acts as the client’s advocate by initiating action to improve healthcare, or to change decisions or activities which are against the interests or wishes of the client, while being aware and sensitive to patient rights
Participates in community-based activities representing the interests of the hospital
Demonstrates excellent communication skills: active listening; use of open-ended questions; ability to reframe and redirect
Demonstrates critical thinking skills
Moves beyond task-based orientation to role-based practice, and focuses attention on responsibility and accountability
Exercises decision authority and demonstrates self-direction, and understands chain-of-command
Acts in a manner that promotes dialogue, open communication and positive working relationships
Strengthens role-based professional practice within the multidisciplinary team
Transfers information and provides care to patients in a manner that is therapeutic as well as interpersonally and culturally responsive
Complies with the ANA Professional Code of Ethics.
Maintains an open, approachable manner, and treats others fairly and respectfully. Preserves others’ self-confidence and dignity, and shows regard for their opinions
Role models integrity and fosters the spirit of teamwork and interdisciplinary encounters by utilizing effective interpersonal skills to resolve conflict
Works closely with hospital staff and physicians to improve documentation in the medical record
Participates in interdisciplinary patient care meetings.
Implements tracking process for identification of high risk/high cost cases requiring further assessment
Participates in evidence-based practice for specific patient populations
Identifies areas for improvement and communicates through the unit-based structure, any recommendation(s) to improve care and outcomes in specific populations
Engages in professional development that increases knowledge and skill related to the professional role, accountability, evidence-based practice and supervision of others
Participates actively in staff development for unit and divisional personnel
Seeks out professional and educational opportunities to increase knowledge of research-based practice
Demonstrates awareness of, and compliance with, patient safety and regulatory and licensing standards; i.e., Joint Commission, Title 22, OSHA, EMTALA, HIPAA, CMS, HSAG and other service-specific regulations
Practices within the scope of the California Nurse Practice Act (Section 2725) in all aspects of patient care, promoting safe practice in order to reduce risk
Adheres to hospital, divisional and unit-based policies and procedures, e.g., attendance and punctuality, chain of command