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RN Care Navigator
2 months ago
Catholic Health is seeking a skilled RN Care Navigator to join our team. As a RN Care Navigator, you will play a critical role in ensuring the seamless transition of patients from acute care to post-acute settings.
Key Responsibilities- Develop and maintain daily active patient tracking mechanisms using available reports and customize spreadsheets to monitor patient progress.
- Visit patients with identified diagnoses, such as CHF/Heart Failure, Pneumonia, and COPD, who meet readmission criteria and those patients identified as high risk for readmission.
- Review and distribute select resource material to patients and families as appropriate, including disease-specific booklets.
- Maintain accuracy of resource material through networking and internet research.
- Serve as a liaison between patient and all other care providers, including physicians, home care agencies, and skilled nursing facilities as needed.
- Assess patients for financial, physical, or psychosocial barriers, including health literacy, and develop strategies to address these barriers.
- Follow patients through the care continuum and collaborate with the treatment team to provide a safe and effective discharge plan.
- Work in conjunction with the Care Coordination Administrative Assistant to schedule post-discharge appointments with the primary care physician or identified specialists within 48 hours of discharge.
- Makes follow-up phone calls to patients as needed to monitor compliance with the plan, medication adherence, diet understanding, and compliance with physician follow-up.
- Attend ICC Rounds for high-risk readmission patients as needed.
- Identify and present process improvement opportunities related to the scope of work and help plan and initiate changes.
- 5+ years of RN experience working in an acute care hospital.
- Experience in care management preferred.
- Skilled in the use of electronic medical records (EMR), MS Office, MS Excel, and MS PowerPoint.
- Graduate of an accredited School of Nursing required.
- New York Registered Nurse (RN) License and Registration required.