Job Description

Position Description

A Nurse Navigator works closely with the Visiting Physician, other health providers and specialty services to maximize the health status of the homebound patient. This position requires contact with the high risk patients and their care givers to perform barrier assessments, offer solutions to improve patient care, serve as an advocate to identify life goals and provide input in the treatment planning process. A Nurse Navigator will also ensure the coordination and communication of a patients treatment plan and general status to all providers and care givers during the continuum of care. This position requires advanced nursing knowledge and expertise to identify a patient need in the home and the ability to direct and implement care coordination plans for hospice or home care when medically appropriate in the home setting.

Essential Duties and Responsibilities

* Provides on-site clinical coordination
* Coordinates the transition of care for patients throughout the continuum to ensure patient needs are met accordingly via case conferencing with providers and continuum partners
* Attends all scheduled VPA and continuum meetings deemed necessary
* Facilitates positive relationship development among the continuum
* Collaborates with all continuum partners (providers, VPA/Grace/PSC staff, patients/families, community agencies, clinical liaisons)
* Serves as an educational resource regarding hospice and home care for providers, patients, and care givers
* Performs a needs assessment of very high risk patients (with their input) to maximize or improve current health status and independence
* Reviews patients' charts to identify gaps in care, potential hospice or home health referrals, and coordinates services with the care team to manage these issues
* Educates the patient and the care giver on the importance of care in the continuum; this will enable providers to communicate with each other, identify gaps in care, reduce hospital readmission, and improve outcomes and patient satisfaction
* Is accessible via phone and email to continuum partners, providers, peers, and supervisor during working hours. Flexibility in work schedule to accommodate needs of patient and care givers
* When necessary or as directed, travel to patient locations such as the hospital, skilled nursing facility, and in the home to assess patient needs and status
* Facilitates communication of patient status and plan of care during transitional experiences such as home to hospital, hospital to post-acute care facility, and back to home. The Navigator will communicate with the providers, patient or care giver, and any specialty program staff that are available, such as hospice, and homecare
* Confirms that appropriate home care, hospice, and other ancillary services are in place and are being delivered as directed by the care team
* Work closely with all providers [Physicians, Nurse Practitioners (NP), Physician Assistants-(PA)] regarding:
* Criteria for hospice and home care referrals
* Community resources in specific geographical service area
* Case conferencing to coordinate care, improve documentation and communication
* Patient education materials
* Facilitates/leads continuum meetings to facilitate appropriate participants discussion regarding utilization of continuum resources to meet patient and family needs
* Assists with documentation to support eligibility of patient under the care of hospice or home care (which may include chart audit worksheet, Labs, diagnostics, History and Physical, Fast Scale, Mortality Risk Scale, etc.*)
* Utilizes clinical tools such as protocols, physician orders, and care coordination models to maximize patient care
* Participates in developing and enhancing tools, and educational programs that promote patient services:
* Provides or arranges for in-services for continuum staff
* Attends all required meetings (monthly staff, etc.) and in-services
* Provides periodic ride-along with Physician Providers (Physicians, NP/PAs)
* Identifies any potential opportunities for improvements within the program/continuum or any needed program development
* Provides/Coordinates educational opportunities for continuum staff on an as needed bases to include participation in new hire orientations
* Completes and submits reports and data on a daily, weekly, and monthly basis to track volume and productivity
* Manages time effectively to ensure all duties and documentation requirements are completed in a timely manner
* Maintains communication with the Director of Nurse Navigators regarding compliance, job performance and significant patient care issues as they arise

REQUIRED Knowledge, Skills, and Experience

* Active R.N. License
* Active CPR Certificate (Florida practices only)
* 1-2 years of hospice experience
* Ability to perform extensive telephone assessment
* Knowledge of Medicare regulations and home care and hospice standards
* Experience with small group presentations and teaching/training
* Understanding of adult learning principles
* Exhibits excellent interpersonal skills
* Working knowledge of computer programs (email, Word, Excel, PowerPoint, etc.)
* Must be very structured, organized, very detailed, and able to meet deadlines

Preferred Knowledge, Skills, and Experience

* Nurse Practitioner License
* Home Health and Care Management experience
* Leadership and/or marketing experience