We re searching for a Nurse Navigator to maintain a central role in coordination, communication, education, and care management for timely, efficient, and cost effective care across multiple healthcare settings (providers, departmental leaders, etc.). Act as the point of contact for patients and families, guiding them through the health care system to promote a positive patient and family experience. Participate in program development through process improvement to ensure the delivery of high quality, evidence based patient care practice in work flow design, protocol and pathway development, and educational material related to disease process.
Long Posting Description
- Actively engages with the patient/family and medical team to assess needs as it relates to diagnoses, care, and discharge plans, and to help establish expectations of care delivery with family.
- Completes NCM assessment and documents in the progress note. The assessment is based on clinical indicators and anticipated services for appropriate level of care considering safety, quality, and cost. The assessment is reevaluated according to changes in condition and when transfers to another location occur.
- Incorporates evidence-based practice in conducting the nursing assessment, care coordination, and the discharge process
- Provides education to the family related to the assessment, available resources, and plan of care.
- Reassesses needs and provides appropriate interventions. Monitors and evaluates patient status.
- Works with patient/family to assess needs related to diagnoses, care, and discharge plans, and to help establish expectations of care delivery with family, ensuring that they are actively involved or represented in the plan of care.
- Maintains up to date information regarding the patient-specific plan of care and current status related to care coordination.
- Leads multidisciplinary care conferences for the patient/family in order to facilitate plan of care progress.
- Ensures communication with interdisciplinary team and works to remove barriers from accessing appropriate healthcare resources and appropriate level of care.
- Analyzes variances from the plan and dispatches departmental and educational resources, communicating anticipated timeframes and working across departments to prevent or resolve delays in service.
- Monitors patient plan of care, and actively works with interprofessional team to remove barriers in order to access appropriate healthcare resources including but not limited to dispatching departmental and educational resources, communicating anticipated timeframes and working across departments to prevent or resolve delays in service.
- Ensures and provides handoffs to internal and external healthcare providers, personnel, and/or community agencies to coordinate services and assist with continuity of care, and serves as liaison for designated specialty.
- Ensures access to outpatient medications including evaluations of co-pay amounts, prior authorization and coordination of delivery/pick-up
- Completes follow-up phone calls on high risk patients-families post-discharge and as needed to decrease re-admissions, ED utilization and negative patient outcomes Communicates needed referrals, pertinent patient information, clinical information, and care plan to all stakeholders in the patient care and referring provider team
- Coordinates scheduled transfer and transport to alternative levels of care when appropriate, to include authorizations for service and Preadmission Screening and Resident Reviews (PASSRs).
- Understands, communicates and collaborates with the Utilization Management (UM) Nurse as necessary to provide information relating to the plan of care, regulatory requirements, payer issues, level of care, and benefits management.
- Identifies and implements plans for high risk patients who are not meeting discharge goals or are high risk for not meeting goals.
- Collaborates with the UM Nurse to identify and document Avoidable Days according to department processes, as applicable.
- Negotiates with third party payers regarding appropriate home care needs when necessary.
- Leads in area of expertise patient support groups, community resources, programs, events, and activities for families to participate in and receive additional support from in the community.
- Assess patient-family education level, needs, barriers and preferred method of learning.
- Works in conjunction with the care team to provide cardiac education to patients and families to meet discharge goals
- Acts as the family liaison to ensure understanding of plan of care and provide support in the decision-making process by empowering parents to learn and care for their child safely, while feeling supported by the cardiac team
- Provides, develops, and refines patient-family education resources in conjunction with the cardiac education team
- Assess staff educational needs and develops educational programs in conjunction with the Service Line Educator.
- Serves as a resource for the clinical care team.
- Serves as the subject matter expert for the patient population. Identifies trends, best practices, and innovations and research/Performance Improvement opportunities.
- Seizes opportunities for professional growth by attending educational conferences, cardiac care conference and seeking out job related evidence based research and participating in creating new policies, protocols and educational resources
- Participates in development, translation, and implementation for disease specific activities to achieve optimum service delivery/systems/care processes.
- Collaborates with leadership and key stakeholders to develop, implement, and evaluate clinical services with an emphasis on coordination across the continuum of care and a goal of aligning healthcare services around the needs of the patient population.
- Advocates for continuous quality improvement process through all initiatives, focusing on system/process improvement.
- Interprets and suggests data to recommend performance improvement activities and research.
- Participates in community outreach or marketing projects to develop a strong relationship with community and referring physicians.
- Performs other duties as assigned
- Demonstrated written and verbal communication skills.
- Ability to apply the nursing process to acute patient care to achieve outcomes.
- Current knowledge of the healthcare environment, including community resources and financial systems.
- Working knowledge of basic computer programs such as word, excel. Knowledge of smart phone use.
EDUCATION AND EXPERIENCE
- Bachelor s degree from an accredited college or university in Nursing required
- Experience with congenital heart disease patients preferred
- Minimum 5 years in nursing required, preferably in a pediatric setting.
- Current and valid Nebraska RN license/RN Compact license required.
- Current and valid Basic Life Support (BLS) through the American Heart Association is required.
- Current and valid Pediatric Emergency Assessment Recognition & Stabilization (PEARS) required within 6-months of hire, unless another position held by the incumbent requires PALS. Employees hired prior to July 24, 2019 are required to obtain PEARS by July 24, 2020.
Children's Hospital & Medical Center - Omaha