RN Transitional Care Navigator-Post Acute

Endeavor Health•Evanston, IL

7d•Onsite

About The Position

The RN Transitional Care Navigator (Population Health) manages and coordinates care and utilization for an assigned patient population across care levels and settings. The role helps patients understand their diagnoses, treatment options, and available resources, connects them with appropriate services, and facilitates safe, smooth transitions across the continuum of care. The navigator serves as a liaison between patients and providers and contributes to outcomes including lower cost of care, optimized length of stay, fewer excess days, reduced SNF utilization and 30-day readmissions, improved SNF transitions, and reduced emergency department utilization. The position is based in Evanston, Illinois, and is full-time at 40 hours per week, typically Monday through Friday from 8:00 a.m. to 4:30 p.m. Possible weekend coverage may be needed in the future, including coverage for team members’ time off. The role may occasionally require travel to patients’ homes and participation in a call-coverage structure for the assigned population.

Requirements

Bachelor’s degree in Healthcare Administration required.
Illinois Registered Nurse (RN) license through the Illinois Department of Financial and Professional Regulation (IDFPR) required.
At least three years of experience in utilization review, discharge planning, case management, or disease management is preferred.
At least two years of clinical nursing experience is preferred.
Ability to communicate and collaborate with a range of stakeholders and team members.
Knowledge of community resources.
Experience with Microsoft Office Suite.
Strong interpersonal and oral communication skills.
Strong computer and data-entry skills.
Proven leadership skills.
Ability to work independently and set priorities to coordinate care plans efficiently.
Adhere to contemporary standards of care established by relevant professional organizations, including AAACN, ACMA, and CMSA.
Interact with and contribute to the professional development of peers and other healthcare providers; share knowledge and feedback to support clinical education.

Nice To Haves

Bachelor’s degree in Nursing preferred.
Nursing experience in home services or ambulatory services working with high-risk patients is beneficial.
Knowledge of InterQual or MCG criteria preferred.
Clinical certification, such as case management certification, is beneficial; case management or ambulatory care nursing certification is preferred.
Experience with an Electronic Medical Record (EMR) platform preferred.
Basic Life Support (CPR and AED) certification from the American Heart Association (AHA) preferred.

Responsibilities

Guide high-risk patients and families through diagnosis, testing, treatment, and follow-up care across the continuum of care.
Remove barriers to healthcare access and facilitate continuity of care and care coordination.
Establish and document individualized, evidence-based plans of care that reflect patients’ health goals and address wellness, health management, disease prevention, and chronic disease management.
Partner with the healthcare team to support timely and appropriate clinical decision-making, implementation of recommendations, and discharge planning.
Coordinate daily with departments, multidisciplinary teams, medical clinics, and community outreach to understand patient needs, promote safety and smooth transitions, and manage utilization and total cost of care.
Partner with social work to provide emotional support, including goals-of-care support and counseling.
Provide or arrange clinical education on medication management, community and financial resources, and other guidance so patients and families can participate meaningfully in healthcare and personal decisions.
Facilitate consultations and support-service appointments within established protocols.
Complete utilization management for assigned patients, applying Milliman Care Guidelines (Indicia) to review admission and continued-stay appropriateness and documenting findings according to department standards.
Monitor length of stay and ancillary resource use, and take action to drive continuous improvement.
Remain available to the assigned patient population and participate in call coverage.
Collect and analyze data to identify under- or over-utilization, improve resource consumption, support cost reduction, and enhance quality of care in line with organizational goals.