Nurse Navigator - Joint Replacement

Yale New Haven Health•New Haven, CT

7h•Onsite

About The Position

The Total Joint Replacement (TJR) Nurse Navigator facilitates the multidisciplinary care of Total Joint patients with the goals of exceptional patient care, patient experience, and clinical outcomes. The TJR Nurse Navigator improves patient preparedness for treatment through education, review of clinical needs, and psychosocial support while also facilitating interaction between patients, their physician (s) and referrals as appropriate. The TJR Nurse Navigator works with the Center for Musculoskeletal, Management and Physician teams to ensure patients are clinically prepared for their surgery.

Requirements

Bachelor's Degree in Nursing required
Three (3) to five (5) years nursing experience in Orthopaedic nursing.
Experience in a combination of the following is essential: clinical care, clinical process improvement, outcomes management, case management and physician relations.
Excellent oral and written communication skills.
Connecticut RN license required
Candidate must be able to thrive in a fast paced, complex academic medical environment where the Total Joint Arthroplasty Nurse Navigator works as a valued member of the multidisciplinary team.
Background in Total Joint Arthroplasty required.
Must possess understanding of clinical processes.
Must be self- motivated, goal oriented and able to work independently.
Must have the ability to develop relationships and work collaboratively and effectively in partnership with patients, families, physicians, clinical staff, and hospital departments.
Must have excellent assessment, communication and organizational skills with the ability to manage and follow through on multiple priorities.
Excellent critical thinking, analysis and assessment skills for successful process improvement planning and monitoring.
Proficient in EPIC and Excel.

Nice To Haves

Master's degree in Nursing preferred.

Responsibilities

Works in collaboration with Service line leadership to review comprehensive risk assessments on all patients who present to YNHH for an elective primary or revision TKA (total knee arthroplasty) or THA (total hip arthroplasty). Based upon results will coordinate and enroll identified high risk patients into one or more risk modification programs.
Directs the process of assessment, planning, facilitation and advocacy for options and services to meet patient?s health needs through communication and identification of available resources to promote quality, patient satisfaction, and cost effective outcomes.
Appropriately optimizes patients with the use of risk modification programs as designated by the service line Leadership team.
Coordinates and assigns all referrals according to defined criteria, including location, and special requirements as needed.
Promotes the use of tele-rehabilitation and collaborates with inpatient and outpatient therapists for follow up.
Provides accurate, comprehensive assessment of relevant medical history and condition, including physical assessment and review of pertinent laboratory results, mental status, and psychosocial support.
Supports collection and documentation in the EMR of Patient Reported Outcomes.
Reviews the medication reconciliation.
Communicates with primary care provider and surgeon regarding optimization of patient.
Assists with Inpatient and post- acute clinical initiatives
Follows patients throughout the continuum to promote adherence to clinical pathways and prevent readmissions.
Maintains responsibility for post discharge patient issues and follows up as appropriate.
Partners with patients and families in addressing their concerns, issues, preferences and needs.
Documents patient and family interactions in the electronic medical record according to established protocols.
Documents multidisciplinary plan of care and achievement of patient goals.
Tracks and monitors patient flow to facilitate patient throughput.
Assists with planning and implementation of a safe discharge and transition of care.
Serves as liaison for the Total Joint Arthroplasty program and provides support to caregivers through guidance and direction in both the inpatient and outpatient settings.
Participates in cross-continuum meetings to promote the TJA program, while monitoring outcomes and trends.
Participates in daily multidisciplinary discharge rounds.
Facilitates and role models a learning environment that supports patient safety and evidence based practice for all levels of patient care staff.
Serves as an essential link between patients and all other care providers.
Responsible for establishing and maintaining positive working relationships with physicians, PAs, nurses, technologists, schedulers, and other ancillary support roles.
Provides support and assistance to internal and external stakeholders, including Service line leadership and Care Management to achieve program goals.
Maintains knowledge base and participates in professional development activities
Maintains knowledge of evidence based medicine.
Maintains clinical competency by participation in continuing education, professional organizations and other related activities.
Collaborates with physicians, nurses and staff to assess educational needs of patients, families and community.
Educates patients and families throughout the continuum, including pre-operatively, during the inpatient stay and post-acute care.
Assesses patient and family understanding of patient condition, goals of care and ongoing management.
Provides patients and families with education regarding their disease process, medications, treatment and plan of care.
Demonstrates Professional Behavior
Collaborates respectfully with staff in all areas of accountability and through matrix relationship with other professional/hospital departments for professional services overseen.
Ensures compliance with all regulatory agencies and accrediting bodies by continuous monitoring of the service operations against existing standards; initiates changes as required.
Participates in committees and projects as directed by Service line leadership.
Collaborates with Service line leadership to provide ongoing education to physicians and clinical staff.