RN Transitional Care Navigator - Care Continuum Community Health

RN Transitional Care Navigator - Care Continuum Community Health

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POSITION SUMMARY

The RN Transitional Care Navigator performs care management within scope of licensure for patients with complex and chronic care needs. Working within a defined patient population, the RN assesses, develops, implements, coordinates, monitors, and evaluates care plans and disease‑specific education to optimize patient health outcomes and resource utilization across the care continuum. The RN meets with patients at the bedside or telephonically to assist in setting realistic health care goals and providing support in reaching those goals through education and care coordination.

The RN performs overall coordination of care for identified patients after discharge to reduce risk of readmission.

Primary Accountabilities

• Works with care teams and technology to identify high‑risk, high‑need patients, implement best practice processes for chronic care and disease management (CHF, AMI, COPD, PNA, CABG and TKR/THR), provide patient education, and refer patients to available health resources when appropriate.
• Facilitates the collaborative management of patient care across the continuum, intervening as necessary to remove and elevate barriers to timely and efficient care delivery.
• Using identified reports, works with Care Transitions team to identify high‑risk patients and assure safe transition to the next level of care to prevent readmissions.
• Utilizes Motivational Interviewing to assess readiness, health goal setting short, and long‑term needs; employs strategies to engage patient’s plans for change that follow standard policy and procedures, clinical guidelines and national evidence‑based criteria.
• Facilitates all discharge phone calls and follow‑up calls, providing interventions as necessary.
• Works collaboratively and maintains active communication with physicians, nursing, physician advisor and other members of the interdisciplinary care team to effect timely, appropriate patient resource management and patient transition.
• Provides patient, family and/or caregiver education as directed by the plan of care.
• Undertakes additional responsibilities as assigned to support departmental operations and organizational objectives.

MINIMUM QUALIFICATIONS

• Education:
  
  Bachelor of Science in Nursing.
• Work Experience:
  
  Two (2) years of strong clinical experience in a clinical practice area.
• Licensure:
  Registered Nurse (RN) Licensure in the State of Florida or endorsement.
• Certification:
  None.
• Work Experience in lieu of
  
  Education:
  
  Associate’s degree in Nursing (ASN) and five (5) years of clinical experience.
• Skills/Knowledge/Abilities:
  • Proficiency in Microsoft Office – Outlook, Word, Excel, PowerPoint, etc.
  • Demonstrates critical thinking, flexibility, and strong organizational skills, effectively managing multiple tasks and priorities.
  • Excellent interpersonal, communication, and negotiation skills, with experience in public speaking and community education.
  • Knowledgeable in managed care concepts, health promotion strategies, and case management, including discharge planning, utilization management, and performance improvement.
  • Strong analytical and data management abilities, with proficiency in PC skills for handling complex data.
  • Skill in time management, prioritizing tasks independently, and exercising sound judgment with physicians, patients, and families.
  • Maintains confidentiality and professionalism in handling sensitive patient and organizational information.
  • Excellent writing and presentation skills for effective communication across various settings.
  • Ability to occasionally work weekends and holidays as needed.

PHYSICAL REQUIREMENTS

• Majority of time involves sitting or standing; occasional walking, bending, and stooping.
• Long periods of computer time or at workstation.
• Light work that may include lifting or moving objects up to 20 pounds with or without assistance.
• May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise.
• Communicating with others to exchange information.
• Visual acuity and hand‑eye…