RN Readmission Navigator

Trinity Health • Darby, PA

2d • Onsite

About The Position

Responsible for driving hospital-wide initiatives to reduce 30-day readmissions and improve patient outcomes, particularly for high-risk populations including heart failure, COPD, sepsis, stroke, and myocardial infarction. This role will proactively identify patients at high risk for readmission, conduct targeted education and coordinate care with inpatient and outpatient providers to ensure appropriate discharge destination. Will also perform post discharge outreach to ensure seamless transition and compliance with treatment plans.

Requirements

• Graduation from an accredited school of nursing.
• Valid RN licensure authorized by the Pennsylvania State Board of Nursing or Compact State.
• At least 5 years of acute care management experience with focus on readmissions, utilization management and/or case management preferred.

Responsibilities

• Oversee proactive identification of patients at high-risk for readmission by utilizing electronic health record analytics and interdisciplinary referrals.
• Collaborates with multidisciplinary teams to assess clinical and psychosocial needs to identify potential barriers in effort to develop a comprehensive discharge plan to mitigate readmission risk.
• Communicates with patient’s acute and ambulatory provider care teams, facilitates patient/caregiver discharge meetings, and provides comprehensive education to support successful transition to next level of care.
• Coordinates post-acute care conferences with post-acute providers including nursing facilities and home health agencies.
• Oversees provider team conferences with patient primary care providers to outline discharge plans as applicable.
• Creates working relationships with primary care providers to provide ongoing readmission education and support to the patient population.
• Establishes collaborative care plans across the acute and ambulatory continuum to ensure patient success in the ambulatory space including updates to patient providers and provider team engagement for patient support and goals of care.
• Participates in all readmission work groups and provides applicable data for review.
• Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies to incorporate into clinical practice.
• Utilizes appropriate conflict resolution, assertiveness, negotiation, and collaboration skills to facilitate patient transition throughout the health care continuum.
• Participates and organizes process improvement projects to decrease readmissions.
• Participates in interdisciplinary rounds with a focus on readmissions.
• Provides metric updates at key meetings as applicable.
• Educates all interdisciplinary teams around readmission reduction.

Benefits

• medical
• dental
• vision
• mental health
• paid time off
• 403B
• education assistance
• pet insurance
• accident insurance
• hospital indemnity

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 251-500 employees