Summary:

The RN Navigator is a member of the patient's care team and acts as a patient advocate providing proactive outreach to patients with chronic illness for the duration of their chronic care condition. The RN Navigator facilitates communication and coordinates care with physicians, the providers' clinic, hospital facilities, family, caregivers and other community healthcare providers and implements creative to meet members/ healthcare needs without compromising quality of outcomes. The RN Navigator will identify and enroll patients with chronic health conditions and/or refer to other programs as appropriate. The RN Navigator will support transitions of care as assigned and/or chronic condition support or health/wellness programs for the assigned population. The position responsibilities also include supporting health risk reduction through goal setting, behavioral change, patient education, and identification of social determinants with appropriate community referrals. In addition, the RN Navigator focuses on reducing preventable admissions, readmissions, and preventable ED visits by supporting discharge planning to the next level of care and educating patients regarding the appropriate setting for care. The RN Navigator connects the patient to health care providers and community resources to ensure ongoing quality of care. The nurse also promotes optimal person-centered care that supports and empowers individuals, respects individual choices and meets health care needs of patients.

• Develops relationships with and facilitates referrals to community resources including Skilled Nursing Facility (SNF), Rehab, Long Term Acute Care (LTAC), Home Health, Hospice, Palliative Care, Transportation, Medication Asst., DME, and other community resources

• Receives and evaluates HH 485 form (Plan of Care) based on Medical Necessity guidelines and Homebound Status requirements.

• Facilitates Case Conferences with HH Agency for evaluation of patient progress toward goals and discharge plan.

• Ensures HH agency is addressing the problem list and providing appropriate follow up for patient needs.

• Based on CMS or other payer guidelines, patient assessment, and case conferences, makes recommendation to PCP re: HH recertification or discharge from service.

• Creates positive relationships with HH agencies as well as Primary Care Clinicians and Office Staff.

• Ensures smooth transition of care along the continuum.

• Facilitates communication between HH agency and PCP practice as necessary to ensure patient's needs are addressed.

• Stays abreast of current CMS and other payer guidelines for HH services.

• Demonstrates expertise in navigating electronic medical record and other care management applications.

• Utilizes MCG Guidelines for Home Care to optimize the type, frequency, and duration of care.

• Monitors key measures of program success and provides feedback re: opportunities to improve.

Requirements:

• BSN Preferred
• 3-5 years acute care/clinical experience; 2-3 years managed care and/or care management experience; experience with high level communication; ability to lead interdisciplinary teams; ability to serve as a patient advocate
• Texas RN License Required

Work Type:

Full Time

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