Care Transitions Nurse Navigator - Full Time - weekend - days

Guthrie Enterprise•Sayre, PA

18h•Onsite

About The Position

The Care Transitions Nurse Navigator is responsible for managing a patient’s successful transition from hospital to home, providing disease management, care coordination, and patient triage. The Nurse Navigator will be responsible for linking mobile resources together, integrate and coordinate them to respond appropriately to patient needs. Telephonic patient triage is provided following established evidence-based protocols to assist in navigating care across the health care continuum. The Navigator is responsible for telemonitoring and patient education activities, and actively coordinates team care in a virtual setting.

Requirements

Graduate from an accredited School of Nursing.
Licensed as a Professional Registered Nurse in both New York and Pennsylvania.
Current license as a Professional Registered Nurse in their state of practice prior to the position’s start date.
Additional state licensure must be obtained within 6 months of hire.
Patient outreach and contact will be limited to those patients living in the state of current licensure until dual licensure is obtained.
Demonstrates knowledge of the principles of growth and development over the life span and possesses the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements as to his/her specific needs, and to provide the care needed as described in the appropriate policies and procedures.

Nice To Haves

Bachelor’s degree in nursing preferred.
A minimum of five (5) years relevant clinical experience who demonstrates leadership and autonomy in nursing practice.
Preferred experience in an emergency or acute care setting, chronic disease management or care transitions.

Responsibilities

Access and navigate EMR System (Epic) to identify patients referred for a community paramedicine visit.
Provide education to the patient virtually at bedside on paramedicine visit and obtain verbal consent for the visit.
Facilitate the referral to the appropriate EMS provider for the initial post-discharge paramedicine visit.
Acts as a primary contact source for patients to escalate concerns, worsening symptoms.
Collaborate with primary care, Care Coordination staff, specialists, EMS crews, Pulse Center team to meet patient needs.
Coordinate deployment of home-based services as appropriate (home health, paramedicine, urgent/emergent EMS response) with appropriate Pulse Center staff and agencies
Schedules follow up appointments for the patient as needed.
Act as a point of contact for patients enrolled in the Chronic Care Management program.
Triage patient questions/concerns, and coordinate care as appropriate
Provide feedback to the appropriate care coordination staff members regarding patient interactions.