RN Transitional Care Navigator - Care Continuum Community Health

Health First Careers • Rockledge, FL

5d • Onsite

About The Position

The RN Transitional Care Navigator provides care management, within the scope of licensure, for patients with complex and chronic care needs. For a defined patient population, the navigator assesses, develops, implements, coordinates, monitors, and evaluates care plans and disease-specific education to improve health outcomes and resource utilization across the care continuum. The role meets with patients at the bedside or by telephone to help them set realistic health care goals and supports progress toward those goals through education and care coordination. The navigator coordinates care for identified patients after discharge to reduce readmission risk.

This is a part-time, onsite position at Viera Hospital. The schedule consists of eight-hour day shifts, listed as 8:00 a.m.–4:30 p.m., with every other weekend. Occasional work on weekends and holidays may be needed. The role may require travel to facilities within and beyond the county perimeter, potentially using a personal vehicle.

Requirements

• Bachelor of Science in Nursing.
• Two years of strong clinical experience in a clinical practice area.
• Registered Nurse licensure in Florida or licensure by endorsement.
• Proficiency with Microsoft Office, including Outlook, Word, Excel, and PowerPoint.
• Critical thinking, flexibility, strong organizational skills, and the ability to manage multiple tasks and priorities.
• Interpersonal, communication, and negotiation skills, with experience in public speaking and community education.
• Knowledge of managed care concepts, health promotion strategies, and case management, including discharge planning, utilization management, and performance improvement.
• Analytical and data-management abilities, including PC skills for handling complex data.
• Time-management skills, ability to prioritize tasks independently, and sound judgment when working with physicians, patients, and families.
• Ability to maintain confidentiality and professionalism when handling sensitive patient and organizational information.
• Writing and presentation skills for communication across varied settings.
• Ability to occasionally work weekends and holidays as needed.
• Alternatively, an Associate’s degree in Nursing (ASN) and five years of clinical experience may be accepted in lieu of the education requirement.

Responsibilities

• Work with care teams and technology to identify high-risk, high-need patients and implement best-practice chronic care and disease-management processes for CHF, AMI, COPD, PNA, CABG, and TKR/THR.
• Provide patient education and refer patients to available health resources when appropriate.
• Facilitate collaborative management of patient care across the continuum, intervening to remove or escalate barriers to timely and efficient care delivery.
• Collaborate with the Care Transitions team using identified reports to find high-risk patients and support safe transitions to the next level of care to prevent readmissions.
• Use Motivational Interviewing to assess readiness, set short- and long-term health goals, and engage patients in plans for change consistent with policies, procedures, clinical guidelines, and national evidence-based criteria.
• Facilitate discharge and follow-up phone calls, providing interventions as needed.
• Maintain active communication and collaboration with physicians, nursing, the physician advisor, and other interdisciplinary care team members to support timely and appropriate resource management and patient transitions.
• Provide patient, family, and/or caregiver education as directed by the plan of care.
• Undertake additional responsibilities as assigned to support departmental operations and organizational objectives.

What This Job Offers

• Job Type: Part-time