RN Transitional Care Navigator - Care Continuum Community Health

Part Time, Onsite role at Viera Hospital

Shift: 8 hour Day Shifts, Every Other Weekend

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 Transitional Care Navigator 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 Transitional Care Navigator 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 Transitional Care Navigator performs overall coordination of care for identified patients after discharge to reduce risk of readmission.

Part Time, Onsite role at Viera Hospital

Shift: 8 hour Day Shifts, Every Other Weekend

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 Transitional Care Navigator 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 Transitional Care Navigator 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 Transitional Care Navigator performs overall coordination of care for identified patients after discharge to reduce risk of readmission.

• 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 .
• Using identified reports, works collaboratively 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; utilizes strategies to engage patient's plans for change that follow standard policy and procedures, clinical guidelines and national evidenced-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.

• Education:
  
  Bachelor of Science in Nursing.
• Work Experience:
  
  Two (2) years strong clinical experience in 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…