RN Transitional Care Navigator - Population Health

Hourly Pay Range

$40.45 - $62.70 - The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.

• Position: RN Transitional Care Navigator-Population Health
• Location:
  
  Skokie, IL
• Full Time: 40 hours
• Hours:
  
  Monday-Friday, 8:30a-5:00p; 2 days onsite required and 3 days remote optional. Weekend and holiday required per rotation. Remote optional for weekend and holiday coverage.

The RN Transitional Care Navigator (Population Health) is responsible for the case management, care coordination management, and utilization management of its patients across multiple care levels and settings. Serves as a catalyst to promote patients understanding their diagnosis, treatment options, and available resources and ensures they are connected with the optimal resources across the continuum of care. This role will coordinate and facilitate smooth and safe care transitions while ensuring quality cost‑effective patient outcomes.

Serves as a liaison between patient population and all other providers. Will be responsible for key metrics of success, which include improving overall cost of care, length of stay optimization, reduction in excess days, reduction in SNF utilization and improvement in SNF care transitions, reduction in 30‑day readmission rate and ED utilization.

• Guide high‑risk patient and family through the health system from diagnosis, testing, treatment and follow‑up care to assist patients with navigating the continuum of care and eliminate barriers to patient access to health care services and facilitate continuity of care and care coordination.
• Establish and document an individualized plan of care for assigned patients using evidence‑based treatment guidelines, considering the patient’s individual health goals with a focus on wellness, health management, disease prevention and chronic disease management.
• Partner with the health‑care team to ensure clinical decision‑making, implementation of recommendations, and discharge planning are timely and appropriate.
• Perform daily coordination between multiple departments, multi‑disciplinary teams, medical clinics, and community outreach to gain knowledge of patient, assure patient safety, smooth transitions of care, and manage utilization and total cost of care.
• Act as advisor/educator by partnering with social work to provide emotional support including goals of care and counseling. Provide and/or arrange clinical education including medication management, community resources, financial resources, and expert guidance to patients and families to promote their understanding and meaningful participation in the health‑care process and personal decision‑making.
• Facilitate appointments for appropriate consultations and support services within established protocols.
• Complete utilization management for assigned patients.
• Apply Milliman Care Guidelines (Indicia) criteria to monitor appropriateness of admissions and continued stays and document findings based on departmental standards.
• Monitor length of stay and ancillary resource use on an ongoing basis and take actions to achieve continuous improvement in both areas.

• Bachelor’s degree in healthcare or related field required or minimum of seven (7) years of appropriate experience.
• Bachelor’s degree in Nursing from an NLN accredited school of nursing is preferred.

RN required

• Clinical certification, such as case management certification, ambulatory care nursing certification is preferred.
• Basic Life Support for Healthcare providers (AHA) or CPR/AED for the Professional Rescuer (American Red Cross) is preferred.

• Minimum three (3) years of utilization review, discharge planning, case management or disease management preferred.
• Nursing experience in home services, ambulatory services working with high‑risk patients beneficial.
• 2+ years of clinical nursing experience preferred.

• Adhere to and practice in alignment with contemporary standards of care as established by leading professional organizations, including but not limited to the American Academy of Ambulatory Care Nursing (AAACN), the American Case…