Pulmonary Disease Navigator - Full Time

Hackensack University Medical Center•Neptune, NJ

63d•Onsite

About The Position

Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives - and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It's also about how we support one another and how we show up for our community. Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change. The Pulmonary Disease Navigator (PDN) is a registered respiratory therapist, who provides care coordination across inpatient and outpatient settings. The PDN will provide clinical expertise through education, knowledge and skills in the area of respiratory care. This role is on-site at Hackensack Meridian Health's (HMH) Riverview Medical Center (RMC). The PDN will play a key role in supporting the network's strategic goals around reducing pulmonary-related readmissions and compliance under the CMS Bundled Payments for Care Initiative (BPCI). Coordinates and administers outpatient diagnostic testing, as related to respiratory care. Provides education to admitted patients on pulmonary disease management and healthier lifestyle choices. Promotes the network and facility-wide quality metrics for pulmonary diseases by clinical expertise and successful disease navigation. Facilitates patients stay from admission to post-discharge to ensure strengthened clinical outcomes. Ensures the delivery of patient care.

Requirements

Graduate of an AMA approved Respiratory Care program.
Associate degree.
Comprehensive knowledge of all clinical aspects of Respiratory Care.
Minimum of 2 years experience as a Respiratory Therapist.
Experience performing Pulmonary Function Test (PFT), Pulmonary Stress Test, 6-minute Walk Test and ABG Draws.
Excellent written and verbal communication skills.
Proficient computer skills that include but are not limited to Google Suite and/or Microsoft Office platforms.
NJ Respiratory Care Practitioner License.
NJ Registered Respiratory Therapist Certificate.
BLS AHA Basic Health Care Life Support HCP Certification.

Nice To Haves

Bachelors of Science.
Previous experience caring for patients with COPD, Pneumonia and other related lung disorders.
Experience with the EPIC electronic-health record system.
Advanced Cardiac Life Support Certification.
Pulmonary Disease Educator certificate.

Responsibilities

Administers outpatient diagnostic testing, including Pulmonary Function Testing (PFT), 6-minute Walk Test, ABG Draws, Cardiopulmonary Exercise Testing (CPET) .
Prepares the diagnostic testing results for the interpreting physician. Faxes results to the referring physician.
Consult with physicians on course of action for the patient's care after PFT diagnostic testing results are analyzed.
Identifies COPD and Pneumonia patients on a daily basis utilizing the EPIC report patient lists.
Reviews patient charts for pulmonary disease coding accuracy and assesses the appropriateness for disease navigation and/or educational visit.
Visits patient at bedside and provide literature, videos, and disease-related education.
Follow-up visits during inpatient stay, as indicated. Continue providing patient education and empowerment.
Coordinates and ensures that patients have follow-up appointments with a Pulmonologist within 7-days of discharge.
Ongoing follow-up on a weekly basis post discharge via phone call or virtual visits to prevent readmission .
Links patients with resources to outpatient diagnostic testing, specifically PFTs.
Provides care coordination for both inpatient and outpatient care. Including a liaison role between the patient, family/caregivers, physicians, nurses and care management.
Provides the patient with post discharge follow-up, including community-based resources for successful disease management.
Partners with the care teams to improve overall facility quality metrics. Specifically, supporting initiatives in COPD and Pneumonia readmission reduction efforts under CMS's Hospital Readmission Reduction Program (HRRP).
Participates in related committees and collaborates across the facility.
Utilizes EHR tools, dashboards, and analytics platforms based on quality metrics and identifies where gaps are. Connects leaders, team members and providers with necessary resources to improve the gaps.
Track and report pulmonary-related patient readmission rates, length of stay, and other identified KPIs aligned with the CMS Bundled Payments and value-based care initiatives.
Assists in community outreach events to market and raise awareness of the facility's Pulmonary Disease programming.
Assists marketing in creating meaningful brochures and other educational materials for physician offices.
Other duties and/or responsibilities as assigned.
Adheres to HMH Organizational competencies and standards of behavior.