rn - clinical care navigator

General Summary:

The RN Clinical Care Navigator, ensures coordination and continuity of care through effective transitions of care management as patients move in and out of the acute care environment and post-acute settings. Providing education, discharge planning to ensure continuity of care across care transitions.

This position requires contact with the high-risk patients and their care givers via hospital visits, telephone calls, or at office visits with the overall goal of decreasing rehospitalizations and ER visits. Duties include but not limited to comprehensive medication reconciliations at discharge, education on disease processes, new medications or treatment, and identification of risk factors contributing to hospitalizations. The RN Clinical Care Navigator will also ensure the coordination and communication of a patient's treatment plan and general status to all providers and care givers during the continuum of care. This position will assist patients in education of finding appropriate care by connecting patients with the appropriate resources. This can occur by phone, email or in-person contact.

Principal Duties & Responsibilities:

Example of Essential Duties:

• Review daily ADT data for hospitalizations and ED visits on identified population.
• Complete Transitional Care calls timely, schedule appointments and document in patient's medical records.
• Monitor that appropriate home care, hospice and other ancillary services are in place and make referrals as appropriate.

• Educate the patient and the care giver on the importance of care in the continuum; this will enable providers to communicate with each other, identifying gaps in care, reduce hospital readmission, improved outcomes and patient satisfaction.

• Complete "Care Calls" to identified patients who are at risk for rehospitalization.

• Participates in Rapid Response calls with QPD at The Toledo Clinic.
• Anticipates customer needs; looks ahead and is prepared to assist in a proactive manner.
• Effectively operates computerized telephone equipment.
• Compiles, maintains, and processes records, data, documentation and reports regarding calls, contacts and actions.
• May assist with or perform research to determine solutions to problems affecting customers.
• Assures that customer is satisfied and documents call appropriately. Follow up on all calls as necessary.
• Initiates problem solving and pursues continuous improvement in customer satisfaction.
• Diffuses emotion of aggravated callers by creating a partnership with the customer.
• Maintains strictest confidentiality.
• Must be able to multi task; speak clearly and professionally over the telephone.
• 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
• Performs other duties as assigned.

Other Essential Duties May Include (but are not limited to):

The above list of duties is intended to describe the general nature and level of work performed by people assigned to this classification. It is not to be construed as an exhaustive list of duties performed by the people so classified, nor is it intended to limit or modify the right of any supervisor to assign, direct and control the work of employees under his/her supervision.

Knowledge, Skills & Abilities Required:

Minimum Qualifications:

• Must have active RN licensure in Ohio and Michigan with 5 years of applicable nursing experience in post-acute settings
• Relevant experience in working with diverse populations
• Must have exceptional problem-solving, critical-thinking, organizational, interpersonal, and written/verbal communication skills.
• Ability to work in self-directed environment with attention to detail and follow-through.
• Must be able to establish priorities and communicate and respond to inquiries.
• Working knowledge of computer programs (email, Word, Excel, PowerPoint, etc.)
• Ability to work effectively with numerous department and administrative levels.
• Willingness to comply fully with all organizational and departmental policies and procedures.