RN, Registered Nurse Navigator Population Health - Irving

Description

Summary :

The RN Navigator is a member of the patient’s care team and acts as a patient advocate providing proactive outreach to patients with chronic conditions. The RN Navigator facilitates communication and coordinates care with physicians, the providers’ clinic, hospital facilities, family, caregivers, and other community healthcare providers. The RN Navigator is committed to being a good steward of resources and collaborates with the patient and implements creative care plans to meet healthcare needs without compromising quality outcomes. The RN Navigator will identify and enroll patients with chronic health conditions in care management programs and / or refer to other programs as appropriate. The Associate will support transitions of care as assigned and / or high-risk outreach for assigned population.

Responsibilities :

Meets expectations of the applicable OneCHRISTUS Competencies : Leader of Self, Leader of Others, or Leader of Leaders.

Fosters health risk reduction through goal setting, behavioral change, patient education, and identification of social determinants with appropriate community referrals.

Focuses on reducing preventable admissions, readmissions, and preventable ED visits by supporting discharge planning to the next level of care and education patients regarding the appropriated setting for care.

Promotes optimal person-centered care that supports and empowers individuals, respects individual choices, and meets patients' health care needs.

Completes initial assessment and plan of care including the patient, their support system, physician, and other health team members to address condition, social determinants, and promote patient knowledge and behavior change.

Develops relationships with and facilitates referrals to community resources including Skilled Nursing, Rehab, Long Term Acute Care, Home Health, Hospice, Palliative Care, Transportation, Medication Asst., DME, and other community resources.

Completes activities pertaining to and achieving quality measures related to payer contracts.

Exhibits behaviors and actions which create a high level of patient satisfaction, contributes to positive patient relations, and reflects respect for a patient’s rights, needs, and confidentiality.

Performs ongoing essential Care Management activities of assessment, barrier and strengths identification, planning implementation, coordination, monitoring, and evaluation of patients. Implements action to overcome barriers to care.

Collaborates with team members in the discharge process, performing outreach / documentation according to CMS guidelines and the Population Health workflow.

Outreach to TOC patients should focus on medication reconciliation / adherence, self-management, use of personal health records, follow-up with PCPs / Specialists, and review of indicators that a patient’s condition is worsening and how to respond.

Promotes a positive work environment by displaying a caring, sensitive approach to others, as evidenced by listening, understanding, and responding to the needs of patients, colleagues, and supervisors.

Ability to serve as a Patient Advocate, communicating high-levelly with patients and all levels of Associates across the organization.

• Performs other duties as assigned.

Job Requirements : Education / Skills

Bachelor’s Degree in Nursing preferred.

Experience

3-5 years of clinical experience required.

2-3 years of managed care and / or care management experience preferred.

Licenses, Registrations, or Certifications

Work Schedule : 5 Days - 8 Hours

Work Type : Full Time

EEO is the law - click below for more information :

https : / / www.eeoc.gov / sites / default / files / 2023-06 / 22-088_EEOC_KnowYourRights6.12ScreenRdr.pdf

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