Aug 08, 2022

RN Navigator, Bundles Care Transition Coordinator

  • VCU Health
  • Richmond, VA, USA
Full time

Job Description

The Nurse Patient Navigator functions as a Nurse Patient Navigator and serves as an advocate, interpreter, educator and counselor for a group of patients.

The Nurse Patient Navigator manages the care of assigned patients in collaboration with a multidisciplinary team to ensure high quality and comprehensive healthcare and ancillary services.

The Nurse Patient Navigator serves as the single point of contact to assigned patients and caregivers.

The Nurse Patient Navigator remains a support system to patients and caregivers throughout the patient’s treatment.

The Nurse Patient Navigator uses clinical/nursing knowledge and skills in the performance of job responsibilities.

Licensure, Certification, or Registration Requirements for Hire:
Current RN licensure in Virginia or eligible or compact state

Licensure, Certification, or Registration Requirements for continued employment:
Current RN licensure in Virginia
AHA BLS Certification
Specialty Nursing Certification in either Nurse Navigation or area of specialty within one year of hire in position

Experience REQUIRED:
Minimum of three (3) years of relevant clinical experience in nursing, patient education; case management and/or navigation
Previous experience in specialty area

Experience PREFERRED:
Previous nurse navigation or leadership experience
Experience within an academic, teaching hospital

Education/training REQUIRED:
Baccalaureate Degree in Nursing from an accredited School of Nursing

Education/training PREFERRED:
Master’ Degree in Nursing from an accredited School of Nursing

Independent action(s) required:
Follows documented physician/licensed independent provider medical/treatment orders.
Practices within the boundaries of the regulations governing the practice of nursing in the Commonwealth of Virginia. Practice is guided by the ANA Code of Ethics for Nursing and established national nursing practice standards. All practice is guided by and follows the VCUHS policies and procedures and established practice guidelines.
Organizes and plans work with input from the patient/family with specific outcomes identified.
Demonstrates use of sound clinical judgment based on nursing knowledge/experience.

Supervisory responsibilities (if applicable): N/A

Additional position requirements:
Positions are primarily weekday work but may be expected to work into the evening or on the weekend, depending on assignment.
May be required to go to all VCUHS locations.

Age Specific groups served:
As appropriate based on unit assignment

Physical Requirements (includes use of assistance devices as appropriate):
Physical - Lifting less than 20 lbs.
Activities: Prolonged standing, Prolonged sitting, Frequent bending, Walking (distance), Climbing (steps, ladder, other), Reaching (overhead, extensive, repetitive): Repetitive motion
Mental/Sensory: Strong recall, Reasoning, Problem solving, Hearing, Speak clearly, Write legibly, Reading, Logical thinking
Emotional: Fast pace environment, Steady pace, Able to handle multiple priorities, Frequent and intense customer interactions, Noisy environment, Able to adapt to frequent change

Navigation enhancement is critical for managing value along the continuum because:

- Bundles Care Transition Coordinators are an advanced task force that supports high-risk patient cohorts as they navigate their care journey.

- Bundles Care Transition Coordinators work with physicians and other case managers/navigators along the continuum to help execute an appropriate plan of care.

-Recovery can take time as well as require multiple treatment protocols — and Bundles Care Transition Coordinators maintain close contact with patients and their support teams.

- Bundles Care Transition Coordinators identify, and take on hospital cases and continue to play a role in the patient’s care for 90 days afterward.

- Bundles Care Transition Coordinators identify the post-acute lead team member who will ensure that cost and quality indicators are being met for the patients. Eg. Home health: Physical therapist supported by RN case manager.

- Bundles Care Transition Coordinators make sure information and care plans transition as patients transition to other levels of care.

-Our Continuum Integration "Center" is a scalable RN/SW resource with standardized care protocols, telehealth technology and provider access, designed to support medical or surgical demands.

Key priorities of the position are:

-To provide excellent care coordination among providers, supporting highest quality care, service, value and satisfaction for both patient and medical staff

-Collaborative practice, which is a key component of constructing a successful bundled payment program

-Encourages communication and coordination of care among a wide variety of providers across care continuum

-Inpatient chart review, making notes in specific relation to Bundle DX and triaging post-acute care needs specific to the patient, payer, and condition

-Collaboration with hospital care coordination team to create effective transition of care plan

-Works with hospitalists, surgeons, primary care and post-acute care providers to align expectations and care protocols/pathways

-Provides 90-day navigation with follow-up patient contact at 48hr, 7d, Weekly 6wk, Bi-weekly 6wk, resetting if there is a readmission

-Follows up closely to ensure adequate and appropriate active care plan is in place

-Utilizes a preferred network of post-acute care providers who are willing to adhere to physicians’ care plans

-Aligns outcome goals and keeps lines of communication open (email and cell# available to all critical parties involved in care journey)

-Employs professional methods and specializes in shepherding care process

-Gives access to supportive resources to address their individual needs, such as transportation assistance

-Schedules appointments, as needed to assure post-discharge care needs are met

-Connects patients with resources to manage conditions such as diabetes, smoking, mental health, and related issues, potentially avoiding adverse outcomes after surgery or hospitalization

-Acts as an extension of the medical team assessing and addressing clinical, social, behavioral risk factors through the 90-day episode

-Captures bundle PI Data precisely; draws trends and educates up/downstream, participating in regular meetings including study of root-cause analysis of readmissions

EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.