Nurse Navigator, Population Health, 40 Hours

UMass Memorial Health•Milford, MA

15d•$83,117 - $149,594

About The Position

Everyone Is a Caregiver At UMass Memorial Health, everyone is a caregiver – regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day. Guides patients through the healthcare system from screening through diagnosis and follow up, by assisting with access issues, developing relationships with service providers and tracking interventions and outcomes. Promotes a positive work environment which emphasizes respect to our customers, patients, patients’ families, providers, caregivers, and other departments. Serves as a clinical expert in the care of these patients. The UMass outpatient OCI High-Risk Nurse Care Manager (RN) role focuses on the following: The High-Risk Care Manager is a PCP-embedded role that provides longitudinal care management for medically complex adult patients in the ambulatory setting. Using strong clinical judgment and critical thinking, the Care Manager develops, implements, and monitors comprehensive care plans that support chronic disease management, care transitions, and patient self-management. The Care Manager partners closely with PCPs, specialists, care teams, patients, and caregivers to coordinate care across the continuum, including hospitals, SNFs, home care, and community resources. Responsibilities include outreach, patient engagement, post-discharge follow-up, health coaching, goal setting, and ensuring timely communication of care plans.

Requirements

Bachelor’s degree in Nursing.
Current Massachusetts Registered Nurse licensure and registration.
Minimum of 5 years nursing experience.
Excellent teaching, consultation, and customer service skills.
Excellent critical thinking skills.
Demonstrates leadership experience.
Excellent verbal and written communications skills.
Computer literate with knowledge of Microsoft Office products.

Nice To Haves

Masters Degree in Nursing.
Skilled with utilization of EMR and other software.
Experience with Project Management.

Responsibilities

Facilitates the entry of patients into the diagnostic and/or treatment system and coordinates their care including family involvement. Follows the patients throughout the continuum of health care services across multiple departments.
Assists patients in understanding their diagnosis, treatment options, recommended follow up and resources available.
Utilizes nursing process to comprehensively assess the patients’ physical and psychological sta-tus.
Evaluates progress of patients along the continuum and is responsible for professional and per-sonal modifications along with the healthcare team as appropriate. May assist with tracking of post care patients to ensure post treatment standards of care are met along with referrals. As necessary, ensures that patients receive clinical satisfaction surveys.
Coordinates and participates in multidisciplinary planning conferences, collaboratively assists with the development of patient summaries for use by care team.
Provides patient and family education across the continuum of care and facilitates symptom management.
Provides access to community resources and links to support services such as: social services, nutrition services, psychologist, pastoral care, physical therapy, rehabilitation therapy, financial counseling, pharmacy, and related organizations. May coordinate and participate in patient support groups with Social Workers.
Assists with tracking metrics and quality indicators for diagnosing and treating promptly and ef-fectively. May assist with production of relevant quality improvement reports.
Develop, implement, support and/or attend related programs/workshops/seminars/support services, etc.
Utilization and optimization of data systems to identify and triage patients and track data out-comes.
May assist with calls to Clinic and perform telephone triage within the scope of practice as a li-censed registered nurse.
May work across multiple campuses and settings.