- Bachelors degree is required
VCUHS is recruiting for a Nurse Patient Navigator, who will serve as a primary navigation resource for Post-Acute Care (PAC) management of post-hospital SNF patients at high risk for readmission and complications.
The role will join the health system's Post-Acute Continuum Services team centered at its Center for Advanced Health Management (CAHM) location, partnering with a PAC SW Specialist, Nursing Facility Attending Service RN Case Manager, CAHM's Clinical Coordinator, and SNFists/NPs in Geriatric Medicine.
The position works closely with the Department of Care Coordination and represents progress in VCUHS's continued advancement on the agenda of transitioning post-acute rehab patients through recuperative care, and back to primary/specialty care while reducing unnecessary utilization and variability in process along the way.
Future clinical and financial success depends on improved integration and coordination of care across the continuum, managing length of stay in the rehab setting, and meeting patient satisfaction demands.
The RN Navigator is a key part of a care team focusing on incentivizing the most efficient modality of care, to deliver on our mission through comprehensive strategy for coordinated patient care and continuum services- moving away from episodic, fractious care, into holistic, integrated and longitudinal support for at-risk patients, social, medical and financial (eg. Bundled Payments).
SPECIFIC DUTIES AND RESPONSIBILITIES:
• In-person, telephonic and electronic review of patients discharged to PAC including Skilled Nursing Facility (SNF).
• Perform assessments that assist in identifying the patient's SNF goals of care, discharge needs and potential barriers.
• Ongoing review of scheduled SNF new admissions, discharges, and any case requiring intervention from a nursing navigation perspective (eg. Bundles).
• Weekly virtual rounds to assure active patient cohort is progressing toward SNF discharge goals and assist to resolve barriers.
• Educate patient, family, staff on the role of the Nurse Navigator, PAC rehab setting, and medical home(s).
• Work closely with Department of Care Coordination, monitoring PAC placements and patients' appropriateness for the selected PAC setting.
• Coordinate and collect data from the SNFist team to inform the discharge plan with a primary goal of providing a safe transition from SNF back to the community setting.
• Highlight care needs, manage to target goals, and improve process to positively impact outcomes, both cost and quality.
• Reduce barriers to discharge/care utilizing VCUHS organization and/or community resources as appropriate, including Home Health Agencies, DME, other.
• Facilitate patient access to appropriate medical providers, including SNFist, Specialist, PCP, otherwise.
• Ensure timely and appropriate follow up appointments are made and adhered to.
• Participate as an active member of the care team collaborating with patient, family, providers, social work, SNF or hospital staff and other care team partners.
• Act as advocate, liaison and information resource for patient and family as well as the SNF staff.
• Collaborate effectively with the care team to establish an optimal discharge plan.
• Document all encounters and patient related discussions, telephonic or in-person, in the patient medical record per organization standards.
• Deliver on our mission through comprehensive strategy for coordinated patient care and continuum services.
• Support and advance vision of holistic, integrated and longitudinal support for at-risk patients.
• Assist with identification of "High Risk" patients and advocate transition to appropriate chronic care program/medical home (eg. VCUHS Advanced Health Homes)
• Maintain accurate records regarding case load, patient needs, risk stratification, and frequency of contact.
• Develop and maintain a listing of community resources and programs and how to access the same.
• Ensure timely and appropriate documentation in Cerner EHR.
• Communicate SNF opportunities/challenges with the Administrator of Post-Acute (PAC) Continuum Services, who manages network partnerships.
• Perform other duties as assigned.
· The right person for this role will be a Registered Nurse (RN) that is goal driven, and has previous experience in clinical or community resources setting.
· Care coordination that extends beyond the acute setting is experience that's desirable. Eg. If you have worked as an intake nurse, nurse navigator, care navigator, care coordinator, palliative care nurse, or a chronic care manager you may be a good fit for this role
· Must have graduated from an accredited school of nursing and be licensed in the state of Virginia.
· Minimum of 2 years field experience.
· Minimum 4 years' experience in Care Coordination, post-acute care (PAC) utilization management, PAC facility management or related area desirable.
· Management of robust quality assurance and/or performance improvement initiatives is preferred.
· Proficiency with Microsoft Office suite including Word, Excel, and Powerpoint is required.
· Experience in innovative care designs, start-ups, and expansions is desirable.
· Must be able to influence patients, family members and post-acute care providers to ensure that care plans are followed and positive patient outcomes are achieved.
The successful candidate will have:
· -Ability to plan, motivate and organize self, others and work in order to achieve objectives and targets.
· -Exceptional interpersonal skills, with demonstrated ability to establish, maintain, and leverage positive, productive working relationships with individuals at all levels throughout an organization.
· -Strong written, verbal and interpersonal communication skills with an acute ability to listen attentively and to communicate effectively throughout all levels of the organization.
· -Group motivation, creativity and diplomacy.
· -Highest level customer service standards.
· -Experience managing complex adult and/or geriatric patient populations, preferred.
Baccalaureate Degree in Nursing from an accredited School of Nursing
Current RN licensure in Virginia or eligible or compact state
AHA BLS Certification
Specialty Nursing Certification – in either Nurse Navigation or Oncology within one year of hire in position
Minimum of three (3) years of relevant clinical experience in nursing, patient education, and/or case management
Previous experience in specialty area