About The Position

Responsible for navigating patients through transitions of care in the healthcare system, inpatient services to outpatient services to home, based on individual and patient population needs. Serves as a clinical resource to patients, families, and staff in the delivery of care to all patients. Works collaboratively with the interdisciplinary team to provide a continuum of care, that is efficient, cost-effective, minimizes fragmentation, and achieves desired treatment outcomes. Ensures communication between patient/family and all healthcare providers.

Requirements

  • Bachelor’s degree (BSN or BS) or two to five years of experience including clinical nursing experience in an acute care setting; or equivalent combination of education and experience.
  • Licensed Registered Nurse in good standing with the State of Michigan
  • Ability to utilize word processing, spreadsheet, presentation programs, databases, and other software relevant to this job.
  • Work which produces high levels of mental/visual fatigue, e.g., interactive and repetitive or small detailed work requiring alertness and concentration for sustained periods of time, the operation of and full attention to a personal computer or CRT between 40 and 70 percent of the time.
  • Involves regularly lifting of bulky or moderately heavy weights (i.e., up to 50 pounds), and occasionally assisting with heavier tasks or expending the equivalent effort in pushing, pulling, or otherwise handling material, equipment, and other objects.

Responsibilities

  • Establishes specialized and specific outpatient multidisciplinary managed care plans or patient contracts for high-risk patients.
  • Revises new scheduling, daily schedule, and staff ratios
  • Coordinates patient and staff educational needs
  • Works collaboratively with the interdisciplinary team to provide a continuum of care, that is efficient, cost-effective, minimizes fragmentation, and achieves desired treatment outcomes
  • Provides oversight of outpatient plan of care to ensure coordination and completion of services to meet outpatient needs
  • Acts as a clinical resource to patients, families, and staff in the delivery of care to all patients
  • Acts as a liaison and facilitator between the patient, physicians, staff members, case managers, primary care physician, outlying hospitals, skilled nursing facilities, and specialty pharmacies
  • Facilitates one on one communication with physician and specialist regarding current and ongoing patient care needs
  • Facilitates multi-disciplinary rounds for staff and huddle boards
  • Coordinates new treatments, medications for offices regarding available services
  • Navigates patients through the healthcare system based on individual and patient population needs with care and financial coordination
  • Identifies appropriate venue and resources for care within the continuum
  • Utilizes critical thinking and problem-solving techniques
  • Is able to work independently, exercising sound judgment, discretion, and initiative to facilitate change
  • Facilitate coordination of care for satellite clinics
  • Documents required work processes and procedures
  • Records data correctly and in standardized format on computer and in writing
  • Participates with and contributes to the development of strategic initiatives related to transitions of care
  • Resource for clerical office staff
  • Service recovery
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