RN Transitional Care Navigator- Chronic and Complex Care Management Program

Nevada System of Higher Education

2d•Hybrid

About The Position

The RN Transitional Care Navigator (Population Health) is responsible for the case management, care coordination management, and utilization management of his/her population of patients across multiple care levels and settings. This role serves as a catalyst to promote patients' understanding of their diagnosis, treatment options, and available resources, ensuring they are connected with optimal resources across the continuum of care. The navigator coordinates and facilitates smooth and safe care transitions while ensuring quality, cost-effective patient outcomes. Acting as a liaison between the patient population and all other providers, this role is responsible for key metrics of success, including improving the overall cost of care, optimizing length of stay, reducing excess days, decreasing SNF utilization, improving SNF care transitions, and reducing 30-day readmission and ED utilization rates.

Requirements

Bachelor’s degree in healthcare or related field required or minimum of seven (7) years of appropriate experience
RN license required
Adheres to and practices in alignment with contemporary standards of care as established by leading professional organizations, including but not limited to the American Academy of Ambulatory Care Nursing (AAACN), the American Case Management Association (ACMA), and the Case Management Society of America (CMSA).
Interacts with and contributes to professional development of peers and other health care providers as colleagues.
Shares knowledge and provides feedback with peers to contribute to an environment supportive of clinical education.
Able to communicate and work collaboratively 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, setting priorities to coordinate care plan efficiently.

Nice To Haves

Bachelor’s degree in Nursing from an NLN accredited school of nursing is preferred.
Clinical certification, such as case management certification, ambulatory care nursing certification is preferred.
Minimum three (3) years of utilization review, discharge planning, case management or disease management preferred.
Nursing experience in home services, ambulatory services working with high-risk patients beneficial.
2+ years of clinical nursing experience preferred.
Knowledge of InterQual or MCG criteria preferred.
Experience with Electronic Medical Record (EMR) platform preferred.

Responsibilities

Guides high-risk patient and family through the health system from diagnosis, testing, treatment and follow-up care to assist patients with navigating the continuum of care.
Eliminates barriers to patient's access to health care services and facilitates continuity of care/care coordination.
Establishes and documents an individualized plan of care for assigned patients using evidence-based treatment guidelines considering the patients individual health goals with a focus on wellness, health management, disease prevention and chronic disease management.
Partners with the healthcare team to ensure clinical decision-making, implementation of recommendations, and discharge planning are timely and appropriate.
Performs daily coordination between multiple departments, multi-disciplinary team, medical clinics, and community outreach to gain knowledge of patient, assure patient safety, smooth transitions of care, and manage utilization and total cost of care.
Acts as advisor/educator by partnering with social work in providing emotional support including goals of care and counseling.
Provides and/or arranges clinical education including medication management, community resources, financial resources, and expert guidance to patients and families to promote their ability to understand and meaningfully participate in the healthcare process and personal decision-making.
Facilitates appointments for appropriate consultations and support services within established protocols.
Completes Utilization Management for assigned patients.
Applies Milliman Care Guidelines (Indicia) criteria to monitor appropriateness of admissions and continued stays and documents findings based on Department standards.
Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas.
May need to travel to visit the patient at home from time to time.
Available to his/her assigned patient population and participates as part of a call coverage structure.
Participates in the collection and analysis of data to identify under/over utilization; improve resource consumption; promote potential reduction in cost; and enhance quality of care consistent with organization strategic goals and objectives.

Benefits

Premium pay such as shift, on call, holiday and more based on an employee’s job (For eligible positions)
Incentive pay for select positions
Opportunity for annual increases based on performance
Career Pathways to Promote Professional Growth and Development
Various Medical, Dental, Pet and Vision options
Tuition Reimbursement
Free Parking
Wellness Program
Savings Plan
Health Savings Account Options
Retirement Options with Company Match
Paid Time Off and Holiday Pay
Community Involvement Opportunities