RN Nurse Navigator

St. Paul's Senior Services•Lafayette, CO

10d•$88,067 - $105,680•Onsite

About The Position

The nurse navigator/transitional care nurse oversees the care of a patient as they move from one health care facility, such as a hospital or nursing home, to another facility or their home. The transitional care nurse ensures the relocation is as smooth as possible and helps the patient remain comfortable during the change. This role includes collaborating with healthcare facility staff and providers, PACE IDT members, the participant and family to determine when and how the move should be made. Once the patient is established in the new facility or back at home, the transitional care nurse will visit them to ensure that everyone needed for a successful transition are in place. The transitional care model (TCM) of health care aims to reduce disruption in care, and thus lower the chances of patients relapsing and having to return to the hospital.

Requirements

License to hold the position of Registered Nurse (RN).
2+ years of RN experience, highly preferred
Must possess BLS/CPR certification or be able to obtain within 60 days of hire.
Must have valid drivers license, reliable transportation, & vehicle insurance coverage at Colorado state minimums.
Must be able to pass all agency health and immunization requirements

Nice To Haves

Experience working with individuals with mental health needs (Preferred).
Experience working with the frail or elderly population (Preferred)

Responsibilities

Coordinates participant care with outside contracted service providers – nursing homes, assisted living facilities, lab, medical equipment, etc.
When participants need ER and/or hospitalization, will initiate collaboration with the receiving facility to ensure they are aware participant is PACE, ensure accurate billing to PACE, and begin the process of determining next steps. Collaboration may be through telephone calls and visits when indicated.
Follow all hospitalized participants from admission to discharge daily and collaborate with PACE IDT members on discharge planning. The TCN will ensure discharge planning is being driven by PACE and will communicate the discharge plan updates to the hospital case manager to ensure smooth transition when the time comes.
When participants discharge a facility (hospital or other facility), will complete a tuck in visit during business hours to ensure all participant needs have been addressed.
Provides education and training to participants and their families on an individual or group basis as needed.
Medication Reconciliation (facility onsite): verifying medications, removing medications, ordering new medications, confirming orders, medication accountability, verifying medications list (Eirene/facility list) documenting differences (if any) and communicating with provider
Facility Rounding: Visit with participant, obtain vitals, head to toe assessment, survey participant needs
Wound care: verifying wound care orders, obtaining wound care supplied, communicating findings to providers.
Collaborate with PACE providers and RN case managers as needed for any discharge needs.
Make death visits to PACE end of life participants as needed during business hours.
When there are no PACE participants requiring the services of the Transitional Care Nurse, they will assist with PACE Home care nursing team with other care visits as assigned.