RN Nurse Navigator- CJRX Comprehensive Care for Joint Replacements

Norman Regional Health System•Norman, OK

1d•Onsite

About The Position

The Transition of Care Nurse Navigator is responsible for providing disease management, care coordination and patient outreach across the care continuum. Collaborates with post-acute providers (home health care, skilled nursing facility, physicians etc.) to improve patient outcomes and reduce preventable hospital readmissions, Medicare Spending per Beneficiary and other goals established by NRHS. Uses persuasion and motivational interviewing to gain cooperation of those not directly accountable to NRHS in an effort to improve patient transitions, outcomes, reduction of preventable readmissions and reduction of Medicare Spending per Beneficiary (MSPB). Effectively coordinates care across the continuum of patient transitions such as skilled nursing facilities, long term acute care hospital and home healthcare. Works closely with the Chronic Care coordinators within the NRHS primary care clinics. Mobilizes post-acute providers to attend routine monthly meetings with the purpose of providing a high quality continuum of care. Performs clinical and readmission reduction data analysis. Acts as supervisor to the post-acute team in the absence of the Transition of Care Supervisor. Reviews NRC survey alerts that require clinical knowledge. Assist NRHS Urgent Care. Meets the changing needs of the Transition of Care Nurse Navigator. Other duties as assigned.

Requirements

BSN required (or other equivalent Bachelor's level of education) but will accept Associates Degree in Nursing with BSN completion within 12 months of hire.
Requires 3 years of experience as an RN.
Current, unrestricted RN license in the state of Oklahoma.
Basic Life Support (BLS) training or retraining is required and must be maintained for the duration of employment.

Nice To Haves

1-2 years of case management or care transition experience.

Responsibilities

Provide disease management, care coordination and patient outreach across the care continuum.
Collaborate with post-acute providers (home health care, skilled nursing facility, physicians etc.) to improve patient outcomes and reduce preventable hospital readmissions, Medicare Spending per Beneficiary and other goals established by NRHS.
Use persuasion and motivational interviewing to gain cooperation of those not directly accountable to NRHS in an effort to improve patient transitions, outcomes, reduction of preventable readmissions and reduction of Medicare Spending per Beneficiary (MSPB).
Coordinate care across the continuum of patient transitions such as skilled nursing facilities, long term acute care hospital and home healthcare.
Work closely with the Chronic Care coordinators within the NRHS primary care clinics.
Mobilize post-acute providers to attend routine monthly meetings with the purpose of providing a high quality continuum of care.
Perform clinical and readmission reduction data analysis.
Act as supervisor to the post-acute team in the absence of the Transition of Care Supervisor.
Review NRC survey alerts that require clinical knowledge.
Assist NRHS Urgent Care.
Meet the changing needs of the Transition of Care Nurse Navigator.
Perform other duties as assigned.