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Registered Nurse Navigator Population Health Senior
2 months ago
We are seeking a highly skilled Registered Nurse Navigator to join our team at Christus Health. As a key member of our population health team, you will play a critical role in providing proactive outreach to patients with chronic illness, facilitating communication and coordination of care with physicians, healthcare providers, and community resources.
Key Responsibilities- Identify and enroll patients with chronic health conditions and/or refer to other programs as appropriate.
- Support transitions of care as assigned and/or chronic condition support or health/wellness programs for the assigned population.
- Develop relationships with and facilitate 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.
- Receive and evaluate HH 485 form (Plan of Care) based on Medical Necessity guidelines and Homebound Status requirements.
- Facilitate Case Conferences with HH Agency for evaluation of patient progress toward goals and discharge plan.
- Ensure HH agency is addressing the problem list and providing appropriate follow up for patient needs.
- Make recommendations to PCP re: HH recertification or discharge from service based on CMS or other payer guidelines, patient assessment, and case conferences.
- Create positive relationships with HH agencies as well as Primary Care Clinicians and Office Staff.
- Ensure smooth transition of care along the continuum.
- Facilitate communication between HH agency and PCP practice as necessary to ensure patient's needs are addressed.
- Stay abreast of current CMS and other payer guidelines for HH services.
- Demonstrate expertise in navigating electronic medical record and other care management applications.
- Utilize MCG Guidelines for Home Care to optimize the type, frequency, and duration of care.
- Monitor key measures of program success and provide feedback re: opportunities to improve.
- 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
