RN Transitional Care Navigator-Post Acute

Endeavor Health•Evanston, IL

9d•$42 - $65•Onsite

About The Position

The RN Transitional Care Navigator (Population Health) manages case management, care coordination, and utilization management for an assigned patient population across multiple levels and settings of care. The role helps patients understand their diagnoses, treatment options, and available resources, and connects them with appropriate services across the continuum of care. The navigator coordinates safe, smooth transitions and supports quality, cost-effective patient outcomes while serving as a liaison between patients and other providers. The position is accountable for outcomes including overall cost of care, length-of-stay optimization, reducing excess days, reducing skilled nursing facility utilization and improving SNF transitions, and reducing 30-day readmissions and emergency department utilization. The role is full-time, 40 hours per week, based in Evanston, Illinois, with a Monday–Friday schedule of 8:00 a.m.–4:30 p.m. Weekend coverage may be needed in the future to cover team members’ time off. Occasional travel to patients’ homes may be required, and the navigator participates in a call coverage structure.

Requirements

Bachelor’s degree in Healthcare Administration required.
At least three years of utilization review, discharge planning, case management, or disease management experience preferred.
At least two years of clinical nursing experience preferred.
Illinois Registered Nurse (RN) licensure through the Illinois Department of Financial and Professional Regulation (IDFPR) required.
Adhere to contemporary standards of care established by professional organizations including AAACN, ACMA, and CMSA.
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, set priorities, and coordinate care plans efficiently.

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.
BLS (CPR and AED) certification from the American Heart Association preferred.
Clinical certification, such as case management certification or ambulatory care nursing certification, preferred.
Experience with an electronic medical record (EMR) platform preferred.

Responsibilities

Guide high-risk patients and families through diagnosis, testing, treatment, and follow-up care, helping them navigate the continuum of care and removing barriers to health services.
Develop and document individualized, evidence-based plans of care that reflect patients’ health goals and emphasize 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 patients’ needs, support safety and smooth care transitions, and manage utilization and total cost of care.
Partner with social work to provide emotional support, goals-of-care support, and counseling; provide or arrange education on clinical matters, medication management, community and financial resources, and healthcare decision-making.
Facilitate appointments for appropriate consultations and support services within established protocols.
Complete utilization management for assigned patients, applying Milliman Care Guidelines (Indicia) to assess admission and continued-stay appropriateness and documenting findings according to department standards.
Monitor length of stay and ancillary resource use, and take action to improve both.
Visit patients at home from time to time as needed.
Remain available to the assigned patient population and participate in a call coverage structure.
Collect and analyze data to identify under- or over-utilization, improve resource use, support potential cost reductions, and enhance quality of care in line with organizational goals.