Registered Nurse Navigator Population HealthSenior-Population Health Admin
Company: Christus Health
Location: Irving
Posted on: May 4, 2024
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Job Description:
Description Summary: The RN Navigator is a member of the
patient's care team and acts as a patient advocate providing
proactive outreach to patients with chronic illness for the
duration of their chronic care condition. The RN Navigator
facilitates communication and coordinates care with physicians, the
providers' clinic, hospital facilities, family, caregivers and
other community healthcare providers and implements creative to
meet members/ healthcare needs without compromising quality of
outcomes. The RN Navigator will identify and enroll patients with
chronic health conditions and/or refer to other programs as
appropriate. The RN Navigator will support transitions of care as
assigned and/or chronic condition support or health/wellness
programs for the assigned population. The position responsibilities
also include supporting health risk reduction through goal setting,
behavioral change, patient education, and identification of social
determinants with appropriate community referrals. In addition, the
RN Navigator focuses on reducing preventable admissions,
readmissions, and preventable ED visits by supporting discharge
planning to the next level of care and educating patients regarding
the appropriate setting for care. The RN Navigator connects the
patient to health care providers and community resources to ensure
ongoing quality of care. The nurse also promotes optimal
person-centered care that supports and empowers individuals,
respects individual choices and meets health care needs of
patients. Responsibilities: Develops relationships with and
facilitates 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. Receives and evaluates HH 485
form (Plan of Care) based on Medical Necessity guidelines and
Homebound Status requirements. Facilitates Case Conferences with HH
Agency for evaluation of patient progress toward goals and
discharge plan. Ensures HH agency is addressing the problem list
and providing appropriate follow up for patient needs. Based on CMS
or other payer guidelines, patient assessment, and case
conferences, makes recommendation to PCP re: HH recertification or
discharge from service. Creates positive relationships with HH
agencies as well as Primary Care Clinicians and Office Staff.
Ensures smooth transition of care along the continuum. Facilitates
communication between HH agency and PCP practice as necessary to
ensure patient's needs are addressed. Stays abreast of current CMS
and other payer guidelines for HH services. Demonstrates expertise
in navigating electronic medical record and other care management
applications. Utilizes MCG Guidelines for Home Care to optimize the
type, frequency, and duration of care. Monitors key measures of
program success and provides feedback re: opportunities to improve.
Requirements: 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. Work Schedule: 5 Days - 8
Hours Work Type: Full Time EEO is the law - click below for more
information: -
https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12ScreenRdr.pdf
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please contact us at (844) 257-6925.
Keywords: Christus Health, Fort Worth , Registered Nurse Navigator Population HealthSenior-Population Health Admin, Administration, Clerical , Irving, Texas
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