Nurse Navigator RN Job Boston area,Massachusetts USA,Nursing

Job Profile Summary

This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. The Nurse Navigator duties include focusing on the patient's needs, guiding the patient through the healthcare system, and overcoming obstacles to receiving necessary care and treatment. This is a professional individual contributor role that may direct the work of other lower-level professionals or manage processes and programs.

The majority of time is spent overseeing the design, implementation, or delivery of processes, programs, and policies using specialized knowledge typically acquired through advanced education.

Job Overview

In conjunction with Case Management, coordinates the transition of care from one healthcare setting to another, which includes inpatient, Home Health Care, Skilled Nursing Facility, and rehab facilities. Educates the patient and/or family regarding the patient's clinical condition, treatment, postoperative course, and the patient's role in recovery. Collaborates and communicates with a wide range of multidisciplinary providers to achieve an exceptional patient experience and the best possible patient outcomes.

Minimum Qualifications

Associate's degree in Nursing.

Registered Nurse (RN) license.

Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) certification.

Three (3) years of clinical experience caring for patients with a broad range of complex medical diagnoses.

Valid, state-issued driver’s license and reliable transportation.

Preferred Qualifications

Bachelor's degree in Nursing.

Advanced Practice Registered Nurse (APRN).

Eligible for state and federal controlled substances registration.

Five (5) years of clinical experience in home health, post-acute, or acute settings caring for patients with a broad range of complex medical diagnoses.

Bilingual.

Duties and Responsibilities

Using effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions, promotes improved quality of care, prevents rehospitalization when possible and appropriate, and ensures appropriate transitions of care, including connections with community and acute services.

Promotes cost-effective nursing, medical and functional outcomes.

Promotes decreased lengths of hospital stays when appropriate with hospital case management transitions of care planning individualized to the patient.

Assures appropriate levels of care are received by patients and involving family caregivers.

Improves transitions of care, identifies drivers of avoidable utilization of Emergency Department (ED) use and hospitalization. Diverts unnecessary ED admissions as appropriate.

Utilizes tele-monitoring as a key modality in the care and monitoring of high-risk patients.

Provides direct patient care/assessment as needed.

Builds relationships and is involved in transitions of care planning to steer patients to appropriate post-acute facility when initial transition to home is not successful (acute vs. subacute rehab, preferred SNF network, etc.).

Monitors active hospital holds working collaboratively with respective liaison and case manager to ensure best transition of care.

Partners with hospital and Care Management teams in the build and sustainability of innovative programs within a strong patient-centered model.

Provides appropriate consultation and referral to Case Management teams.

Identifies appropriate alternative and non-traditional resources and demonstrates creativity in managing each case to fully utilize all available resources to meet medical and social determinants of health.

Maintains accurate records of all interventions and provides timely verbal and written reports, as directed.

Prepares regular management reports.

Maintains accurate records of all communications and interventions.

Ensures compliance within guidelines set forth by regulatory agencies (DPH, ERISA, etc.) and demonstrates compliance with Home Health Foundation policies and procedures.

Practices confidentiality principles set by the agency and federal HIPAA/HITECH guidelines.

Physical Requirements

Prolonged, extensive, or considerable…