Job Description

Position Description

A Nurse Navigator works closely with the Visiting Physician, USMM’s in home health care continuum and specialty services to maximize the health of the VPA patient. This position requires home visits to the high risk patients and their caregivers to perform assessments, serve as an advocate to identify life goals, provide input in the treatment planning process and offer solutions to improve patient care. A Nurse 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 requires advanced nursing knowledge and expertise to identify gaps in care, provide education, assist with resources, partner with continuum to reduce unplanned hospitalizations and ensure the right care at the right time.

Essential Duties and Responsibilities

Provides on-site clinical coordination
Spend quality time with our patients and families identifying gaps in care, providing education, assisting with community resources and partnering with our continuum in an effort to reduce unplanned hospitalizations and help ensure the right care at the right time
Coordinates the transition of care for patients throughout the continuum to ensure patient needs are met accordingly via case conferencing with providers and continuum partners
Attends all scheduled VPA and interdisciplinary meetings
Facilitates positive relationship development among the continuum

Collaborates with all continuum partners (providers, VPA/Grace/PSC staff, patients/families, community agencies, clinical liaisons)
Serves as an educational resource regarding palliative care and home care for providers, patients, and care givers
Perform basic nursing assessment of patients (with their input) to maximize or improve current health status and independence to assist with avoiding unnecessary hospitalization or emergency visits to include but not limited to: urine analysis, blood sugar testing as needed based on patient care
Review of medical records to identify gaps in care, potential hospice or home health referrals, and coordinate services with the care team to manage these issues
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
Is accessible via phone and email to continuum partners, providers, peers, and supervisor during working hours
When necessary or as directed, travel to patient locations such as hospital, skilled nursing facility, an in the home to assess patient needs and status
Facilitate communication of patient status and plan of care during transitional experiences such as home to hospital, hospital to post-acute care and back to home
Communicate with the providers, patient or care giver, and any specialty program staff that are available, such as hospice, and homecare
Confirm that appropriate home care, palliative care and other ancillary services are in place and are being delivered as directed by the care team
Works closely with all providers to include Physicians, Nurse Practitioners (NP), Physician Assistants-(PA) regarding:

Criteria for palliative care and home care referrals
Community resources in specific geographical service area
Case conferencing to coordinate care, improve documentation and communication
Patient education materials

Assists with documentation to support eligibility of patient under the care of hospice or home care (which may include chart audit worksheet, Labs, diagnostics, History and Physical, Fast Scale, Mortality Risk Scale, etc.*)

Utilize clinical tools such as protocols, physician orders, and care coordination models to maximize patient care.

Participates in developing and enhancing tools and company initiatives that promote patient services
Provides or arranges for in-services for continuum staff
Attends all required meetings (monthly staff, etc.) and in-services
Provides periodic ride-along with physician Providers (Physicians, NP/PA’s)
Identifies any potential opportunities for improvements within the program/continuum or any needed program development
Provides/Coordinates educational opportunities for continuum staff on an as needed bases to include participation in new hire orientations
Complete and submit reports and data on a daily, weekly, and monthly basis to track volume and productivity

Manages time effectively to ensure all duties and documentation requirements are completed in a timely manner
Maintains communication with the Regional Director- Medical Management regarding compliance, job performance and significant patient care issues as they arise
Maintain productivity expectations related to patient visits, telephonic outreach assessments and other duties as assigned

REQUIRED Knowledge, Skills and Experience

Active R.N. License
Active CPR Certificate
2 or more years of direct home health experience
Must maintain a valid driver’s license and good driving record
Ability to perform extensive telephone assessment
Knowledge of Medicare regulations and home care and hospice standards
Experience with small group presentations and teaching/training
Understanding of adult learning principles
Exhibits excellent interpersonal skills
Exhibits excellent written and oral skills
Working knowledge of computer programs (email, Word, Excel, PowerPoint, etc.)
Must be self-motivated, independent, structured, organized, very detailed and able to meet deadlines

Preferred Knowledge, Skills and Experience

Bachelor of Science
6 month experience of home health
1 year experience of care management
1 year experience of discharge planning
1 year leadership and/or supervisory experience