Nurse Navigator - Joint Replacement

Overview

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient‑centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

The Total Joint Replacement (TJR) Nurse Navigator facilitates the multidisciplinary care of Total Joint patients with the goals of exceptional patient care, patient experience, and clinical outcomes. The TJR Nurse Navigator improves patient preparedness for treatment through education, review of clinical needs, and psychosocial support while also facilitating interaction between patients, their physician(s) and referrals as appropriate. The TJR Nurse Navigator works with the Center for Musculoskeletal, Management and Physician teams to ensure patients are clinically prepared for their surgery.

EEO/AA/Disability/Veteran

• 1.1.1 Works in collaboration with Service line leadership to review comprehensive risk assessments on all patients who present to YNHH for an elective primary or revision TKA (total knee arthroplasty) or THA (total hip arthroplasty). Based upon results will coordinate and enroll identified high risk patients into one or more risk modification programs. 1.2 Directs the process of assessment, planning, facilitation and advocacy for options and services to meet patient’s health needs through communication and identification of available resources to promote quality, patient satisfaction, and cost effective outcomes.
  
  1.3 Appropriately optimizes patients with the use of risk modification programs as designated by the service line Leadership team. 1.4 Coordinates and assigns all referrals according to defined criteria, including location, and special requirements as needed. 1.5 Promotes the use of tele‑rehabilitation and collaborates with inpatient and outpatient therapists for follow up. 1.6 Provides accurate, comprehensive assessment of relevant medical history and condition, including physical assessment and review of pertinent laboratory results, mental status, and psychosocial support.
  
  1.7 Supports collection and documentation in the EMR of Patient Reported Outcomes. 1.8 Reviews the medication reconciliation. 1.9 Communicates with primary care provider and surgeon regarding optimization of patient.
• 2.2. Assists with Inpatient and post‑acute clinical initiatives 2.1 Follows patients throughout the continuum to promote adherence to clinical pathways and prevent readmissions. 2.2 Maintains responsibility for post discharge patient issues and follows up as appropriate. 2.3 Partners with patients and families in addressing their concerns, issues, preferences and needs. 2.4 Documents patient and family interactions in the electronic medical record according to established protocols.
  
  2.5 Documents multidisciplinary plan of care and achievement of patient goals. 2.6 Tracks and monitors patient flow to facilitate patient throughput. 2.7 Assists with planning and implementation of a safe discharge and transition of care.
• 3.3. Serves as liaison for the Total Joint Arthroplasty program and provides support to caregivers through guidance and direction in both the inpatient and outpatient settings. 3.1 Participates in cross‑continuum meetings to promote the TJA program, while monitoring outcomes and trends. 3.2 Participates in daily multidisciplinary discharge rounds. 3.3 Facilitates and role models a learning environment that supports patient safety and evidence based practice for all levels of patient care staff.
  
  3.4 Serves as an essential link between patients and all other care providers. 3.5 Responsible for establishing and maintaining positive working relationships with physicians, PAs, nurses, technologists, schedulers, and other ancillary support roles. 3.6 Provides support and assistance to internal and external stakeholders, including Service line leadership and Care Management to achieve program goals.
• 4.4. Maintains knowledge base and participates in professional development activities 4.1 Maintains knowledge of evidence based medicine. 4.2 Maintains clinical competency by…