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
- 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.
EDUCATION AND WORK EXPERIENCE
- Graduate of an accredited program for nursing education, BSN preferred.
- Current licensure to practice professional Nursing in the State of Ohio.
- Current American Heart Association (AHA) Healthcare Provider CPR (BLS) certification required.
- Two (2) years’ experience in clinical or community health setting caring for chronic disease patients or previous Care Coordination preferred.
- Working knowledge of Joint Commission.
- Previous telephonic patient care management, preferred.
- Care Coordination and Transition Management Certification or similar certification preferred.