RN Chronic Care Navigator, DOPC Population Health, FT

JOB SUMMARY

The  Chronic  Care  Navigator  seeks  to  ensure  the  importance  of  services  delivered  to  the  patient  by facilitating  beneficial,  efficient,  safe,  and  high  quality  patient  experiences  while  improving  patient satisfaction.  Participates in direct  and  indirect patient  care  by utilizing  the  nursing  process,  designated  scope  of  practice  through  data  collection, applying critical thinking skills and motivational interviewing techniques to promote the delivery of safe, quality, and age specific care.  Works  diligently  with  partnered  insurers  to  participate  in  quality  incentive  programs with  the  goal  of  revenue  maximization  and  value.  Helps  achieve  optimal  healthcare  outcomes  and promote  wellness  by  coordinating  care  and  disease  management  to  high  risk  patients.  Works collectivity  with  other service lines  to  reduce  readmissions  and  unnecessary  ED  visits.  Effectively closes care gaps around specialty and chronic disease. Documents accurately and in a timely manner.  Communicates effectively with other healthcare team members.  Adheres  to  organizational  and  department  policies  and  procedures;  regulatory  and accrediting  body  requirements;  and  professional  practice  standards.

KNOWLEDGE AND SKILLS

• Current  knowledge  of  the  nursing  role  and  scope  of  practice  as  defined  by  the  State  of  Ohio Nurse  Practice  Act  and  the  Ohio  Board  of  Nursing.
• Current  knowledge  of  the  American  Nurses  Association  (ANA)  Code  of  Ethics.
• Demonstrated  ability  to  actively  manage  change,  resolve  conflict,  problem-solve,  and  make decisions.
• Knowledge  of  current  trends  in  care  coordination  and  population  health.
• Successful completion of mandatory requirements including department competencies.
• Demonstration of effective interpersonal and team work skills.
• Demonstration of effective verbal and written communication.
• Demonstration of positive customer service.

EQUIPMENT/TOOLS/SOFTWARE

• Basic computer literacy (keyboarding; order entry; word processing)
• Web based platforms
• Computerized documentation programs

PRIMARY JOB RESPONSIBILITIES

• Delivers comprehensive, coordinated care management through team based care and best practices to all patients across the continuum.
• Assesses/reassesses  patient's  condition  based  upon data collection and interview of patient  and/or  family, diagnosis, diagnostic  results,  and  relevant  data from  other  healthcare  providers.
• Uses  professional  knowledge  to  develop/  revise  nursing  plans  of  care  for  assigned  patients according expected  quality outcome(s).
• Evaluates/re-evaluates patient’s response to nursing interventions and patient’s progress to expected quality outcome(s).
• Delivers  safe  nursing  interventions  in  an  organized,  efficient,  and  prioritized  manner  to address  identified  needs.
• Proactively acts as a patient advocate, responding with empathy and respect to resolve patient/family concerns.
• Provides patients and family members with  relevant  health care education  and  instructions regarding  treatments  and  procedures  including  pre/post  hospital  care  as  appropriate.
• Documents  all  aspects  of  patient  care  and  maintains  patient  records  in  a  timely  manner  as  appropriate  for department.
• Coaches patients/families toward successful self-management of chronic disease state
• Supports the mission, values, and vision of the organization.
• Represents  department  and/or  hospital  on  appropriate  internal/  external  committees  and functions.
• Collaborates and communicate effectively with team members, providers, and  community  partners  to  coordinate  the  medical  and  nursing  plans of  care.
• Maintains patient, employee, provider, and organization confidentiality; respects the rights, privacy, and property of others.
• Delegates responsibilities to appropriate personnel and accepts delegated responsibilities within scope.
• Assumes  responsibility  and  accountability  for  individual  knowledge,  skills,  performance  and behavior  in  accordance  with  hospital,  division,  and  department  standards  of  care  and policies  and  procedures.
• Complies with all hospital and department policies.

ADDITIONAL RESPONSIBILITIES

• Core Values consistent with a patient/family-centered approach to care.
• Performs  tasks  that  are  supportive  in  nature  to  the  essential  functions  of  the  job  including ability  to  detect  early  and  manage  effectively  the  chronically  ill  patient  population.
• Demonstrates knowledge of disaster/emergency procedures and responds appropriately.
• Participates and provides feedback in interdisciplinary meetings, staff meetings,    educational programs, committees, QI activities and mandatory in-services.
• Participates in maintaining department functions and assists  with  control  of  costs  through  the  judicious  use  of  human  and  material  resources.
• Demonstrates continual learning skills, changes in approach to care based on established evidence-based practice and demonstrates initiative in personal and professional development including obtaining Care Coordination and Transition Management Certification or like certification at director’s discretion.
• Presents  a  professional  image
• Assists  in  the  orientation, training and mentoring of new and tenured personnel,  reassigned  nurses, student  nurses  and  faculty;  serves  as  a  preceptor  when  requested.
• Other duties as assigned.