Nurse Navigator

Nurse Navigator - Outpatient Clinic

Location :
Coldwater, MI

Job Summary:

The RN Acute Care Navigator is responsible for direct patient care focusing on:
Care

Progression/Care Coordination, Level of Care, Length of Stay, Readmission Prevention, Value

Based Programs, Daily Transition Rounds (DTRs), Discharge Planning and compliance for their

assigned caseload to ensure appropriate patient throughput. Compliance requirements include

but are not limited to:
Maintains working knowledge of Condition Code 44 Intervention, Second

IMM, MOON/Observation Status notification, Advanced Directives, Beneficiary notices, and

Patient Choice. The RN Acute Care Navigator is responsible for collaborating with patient's care

team (Physicians, Nurses, Social Workers, Ancillary Services, Care Navigation Resource Center

Coordinators, Contracted Vendors, etc.) and escalating appropriately to ensure their assigned

patient receives exceptional care and avoids unnecessary delays in care progression or discharge.

Duties:

* All duties listed below are essential unless noted otherwise
* 1. Conducts in person Initial Assessment with patients/caregivers including identification of

patient decision maker as appropriate, with goal of Initial Evaluation completion within 24

hours of admission.

2. Develops Discharge Plan (with associated contingency plan) within 24 hours of admission;

updates, as appropriate.

3. Assesses patients to determine ability for self-care and to identify those most at risk for post discharge

adverse health consequences without intensive discharge planning. Provides a

discharge planning evaluation to those patients identified as at risk and upon the request of

the patient, key stakeholders, members of the interdisciplinary team or the physician.

4. Conducts a comprehensive assessment of the patient's physical, psychosocial, spiritual,

environmental, and caregiver status to identify post-hospitalization needs. Documents all

findings in the EMR. Identifies patients most at risk for readmission without intensive

discharge planning through information gathered on the admission nursing database,

electronic medical record (EMR) predictive analytics tools, and proactive case finding.

5. Completes Readmission Assessment on readmitted patients.

6. Shares Readmission Risk score daily during DTRs; collaborates with interdisciplinary team to

identify high risk patients whose risk score may not have indicated appropriately;

implements interventions according to risk score.

7. Identifies transitional care barriers and collaborates in comprehensive, patient-centered care

plan development. Reassesses patients and revises the plan as applicable.

8. Implements Discharge Plan; inclusive of Discharge Plan communication and confirmation and

includes patients/caregivers in Discharge Plan development to gain participation, agreement,

and accountability.

9. Stratifies assigned patients by Clinical, Financial, and Psychosocial risk factors and submits

follow-up referrals, as appropriate.

10. Consults Social Work for complex discharges and psychosocial/SDOH needs.

11. Develops, documents, and communicates Care Coordination Plan, updates as appropriate.

12. Collaborates with UM team, as appropriate and applies clinical understanding of medical

necessity criteria, patient status and discharge criteria and assists UM team by relaying

potential changes in medical necessity/appropriate patient status/LOC.

13. Reviews necessary patient information, including lab and other test results and progress

notes in patient health record daily.

14. Collaborates and actively engages patients and key stakeholders throughout interdisciplinary

progression and coordination of care along with the discharge planning process to ensure a

patient-centered plan and document accordingly.

15. Partners with physicians as appropriate for care progression, care coordination and

appropriate length of stay and collaborates with other key team members to manage

transitional care activities and communicate vital information.

16. Actively participates in DTRs and facilitates discussion of progression and discharge needs.

17. Establishes initial Estimated Discharge Date (EDD), updates, as appropriate.

18. Discusses…