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RN Navigator Physicians Clinic

Methodist Health System Omaha, NE
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Job Description

  • Purpose of Job
    • A registered nurse who is part of the primary and specialty care practice team and is responsible for providing care coordination and care management services to patients within the practice who are most at risk for health deterioration, sentinel events, and/or poor outcomes.

    • The highest risk patients are identified via multiple sources to include:
      • Patients identified by other health coaches, case managers and health care providers
      • Patients with high risk scores identified by IT via HealtheIntent
      • Those identified via IT algorithm as a rising risk patient
      • Patients identified by insurance carrier as high risk

    • These patients will include:
      • Uncontrolled or poorly compliant patients with COPD or heart failure
      • Patients with frequent ER utilization
      • Non-cancer patients admitted to inpatient services greater than two times in past year

    • The Care Navigator is an integral part of the primary/specialty care team is responsible for ensuring that the primary care physician (PCP)/specialist and practice team maintains a central role in coordinating and managing the care of these vulnerable patients and that the patients receive optimal care including acute illness management, chronic disease management, and preventive care across multiple health settings and multiple physicians/providers.
  • Job Requirements
    • Education
      • Successful completion of annual mandatory education requirements.
      • Bachelor of Science in Nursing (BSN) from an accredited school of nursing required.
      • Extensive navigator or care management experience may be acceptable in place of BSN. Registered Nurse (RN) licensure required.

    • Experience
      • 5 years of previous clinical experience required.

    • License/Certifications
      • Current valid license, valid compact multi-state license, or a temporary permit while awaiting licensure required for work state.
      • Current American Heart Association Basic Life Support (BLS) certification required.
      • ACLS required for Care Navigator working at Heart Consultants, Pulmonary Specialists or Heart Care Center.

    • Skills/Knowledge/Abilities
      • Ability to multitask and prioritize work assignments.
      • Knowledge of medical diagnoses, procedures and treatment protocols.
      • Ability to critically listen and respond to patient questions and requests and provide education as appropriate.
      • Knowledge of HIPAA requirements and organizational expectations for confidentiality.
      • Ability to problem solve and provide effective solutions.
      • Strong verbal communication skills for positive interactions with patients, coworkers, physicians and the general public.
      • Knowledge of medical and community resources available for patient referral and support.
  • Physical Requirements
    • Weight Demands
      • Medium Work - Exerting up to 50 pounds of force.

    • Physical Activity
      • Occasionally Performed (1%-33%):
        • Climbing
        • Crawling
        • Kneeling
        • Sitting
      • Frequently Performed (34%-66%):
        • Balancing
        • Carrying
        • Crouching
        • Distinguish colors
        • Keyboarding/typing
        • Lifting
        • Pulling/Pushing
        • Repetitive Motions
        • Stooping/bending
        • Twisting
      • Constantly Performed (67%-100%):
        • Fingering/Touching
        • Grasping
        • Hearing
        • Reaching
        • Seeing/Visual
        • Speaking/talking
        • Standing
        • Walking

    • Job Hazards
  • Essential Job Functions
    • Essential Functions I


      • Management of patients identified by the PCP/Specialist team as highest risk.
        • Maintenance of a care management registry for documentation of highest risk patients, care management interventions, and care plans.
        • Triaging high risk patients to identify the highest risk patients based on severity of disease, self-care limitations, lack of family support, severe socioeconomic factors, poly-pharmacy, and health care utilization trends.
        • Evaluation of and appropriate follow-up care for patients with frequent visits to the emergency department to prevent further disease exacerbation, untoward complications, or additional ER or hospital utilization.
        • Timely and ongoing communication with the PCP/Specialist and practice team to identify highest risk patients and to maximize the management of patient needs and related risk reduction.

      • Care management of highest risk patients to reduce risk, decrease hospital and ER utilization, and improve outcomes.
        • Performs a comprehensive initial and ongoing assessment of patients physical, mental and psychosocial needs.
        • Prioritizes data collection according to patient's immediate needs.
        • Assuring that care is patient-centered and that the patient/family are informed about the plan of care, integrated in to the care coordination, planning and supported in decision-making.
        • Coordinating care with other health coaches and care managers across the continuum of care and payers to maximize care and promote patient safety.
        • Communicating/affirming patient needs, plan of care, and changes in status with the PCP, team and the patient/family.
        • Oversight of the care coordination system for rising risk and high risk patients that is managed by the practice team.

      • Development of a tracking system for patient care coordination and care management across the continuum, including care transitions, referrals, report management, and two-way communication between the PCP, specialists, and/or other providers.
        • Assure database is kept up to date.
        • Identify patients overdue for visits, labs, referrals and arranging for follow-up services as appropriate and prescription refills.
        • Identify patients who are not meeting clinical goals, such as BP control or glucose control, and arranging for follow-up services by protocol or as appropriate.
        • Create patient, physician, and clinic level quality performance reports

      • Developing/managing tracking and documentation systems for patients admitted to and discharged from the hospital, patients seen in the emergency room (ER), and patients transitioning from or to any other health care facility.
        • Transition care for patients discharged from the hospital within 24 - 48 hours to prevent readmission and related complications.
        • Developing care plans that prevent disease exacerbation, improve outcomes, increase patient engagement in self-care, decrease risk status, and minimize hospital and ER utilization.

      • Developing/managing care coordination systems that support referral, test completion and report receipt, and an integrated plan of care with specialists and other providers across the continuum.
        • Utilizing behavioral strategies to assist patients in adopting healthy behaviors, improving self-care and managing chronic disease.
        • Assisting patients in problem-solving issues related to the health care system, financial and psychosocial barriers.
        • Ongoing evaluation and documentation of patient progress/risk status and appropriate scheduling of high risk health coaches interventions.
        • Communicating/affirming patient needs, plan of care, and changes in status with the PCP, team and the patient/family.
        • Oversight of the care coordination system for rising risk and high risk patients that is managed by the practice team.

      • Training of office staff in the coordination of care with specialists and other providers.
        • Develops/reviews/revises and individualizes the plan of care to address the patient's needs for optimum patient care outcomes and communicates the plan with appropriate care team members.
        • Collaborates with providers and other clinical disciplines as appropriate.
        • Provides teaching specific to the patient.
        • Care plan reflects continuing care needs and/or referrals.

      • Implements interventions that are consistent with the established plan of care in a safe and appropriate manner.
        • Is familiar with, and follows, protocols and standards of care.
        • Uses current knowledge in nursing practice based on standards and research literature.

      • Performs technical skills competently and independently to assure patient safety.
        • Able to competently perform technical skills independently.
        • Is accountable to learn new skills and equipment within areas' specifications and time frame.
        • Demonstrates correct and safe technique in the use of equipment according to specific product information and policy and procedure manuals.
        • Follows appropriate procedure for obtaining and returning or cleaning/disposing of equipment and supplies.

      • Maintains a professional behavior in attitude, demeanor, interactions to achieve organization's mission.
        • Communicates effectively to solve problems at the personal and team level.
        • Is approachable and professional in working with other health professionals, ancillary staff, patients and family.
        • Takes pride in the clinic by active participation in restocking and maintaining a clean environment.
        • Maintains a professional appearance, behavior, and work environment.
        • Maintains competence in area of experience.
        • Participates in meetings and/or committees as needed to assist in decisions effecting area/unit or organization.

      • Initiates action to correct, prevent, and/or minimize risk(s) to the patient, family or staff/employees.
        • Communicates to appropriate personnel regarding unresolved issues.
        • Works within the scope of practice as defined by Nurse Practice Act.

      • Fiscally accountable.
        • Acts professionally responsible for human and other resources.
        • Charges accurately for use of supplies and equipment according to policy.

      • Evaluation/Assessment
        • Partners with and has daily communications with physicians regarding the medical plan of care, progression to the next level of care, and criteria for discharge.
        • Comprehensively assesses each patient/family when admitted (the day of admission or next day if admitted on off-shifts or Monday a.m. if admitted on the weekend) for medical, psychosocial, financial, and discharge needs.
        • Collaborates with clinic and hospital departments to ensure the utilization of appropriate care plans, care paths, and/or order sets.
        • Monitors caseload daily for variances to patient progression and collaborates with physician and/or care team to address.

      • Communication
        • Develops and maintains an effective daily communication plan with physicians, incorporating their preferences.
        • Communicates to team members a clinical picture of what the patient should look like at discharge (criteria for discharge).
        • Flexes work schedule to accommodate hospital rounds, clinic visits and maximize direct communications.
        • Communicates effectively with nursing and other team members to plan for and facilitate the efficient delivery of acute and post-acute care.
        • Establishes effective relationships with patient/family to set reasonable goals and expectations for acute care, and to facilitate a safe and satisfactory transition to home or alternative post-acute facilities.
        • Accurately documents in the medical record, and/or electronic system and completes forms in accordance with documentation policies.
        • Gives succinct, pertinent case presentations for review of complex cases.
        • Tracks and communicates pertinent results (i.e., diagnostics and consulting physician recommendations) in timely manner to physician(s) to expedite medical decision making.
        • Provides education and acts as resource about the knowledge and practices of high risk patient case management to staff, physicians and other members of the care team.
        • Actively participates in interdisciplinary rounds and targets actionable issues affecting patient care and clinical progression.

      • Planning and Facilitation
        • Organizes and prioritizes workday to enable interaction with the hospital and clinic care teams and patients/families.
        • Analyzes patient caseload and gathers current information about patient condition and plans of care, i.e.; medical Plan of Care (POC), patient care plans, and discharge plan.
        • Facilitates timely referrals to care team (i.e.: Social Work, Rehab, CHF HRHC, Wound Care, Diabetes Clinic, and Anticoagulation Clinic).
        • Provides pertinent clinical information to Social Work to facilitate needed discharge arrangements.
        • Mentors nursing staff in managing patients' clinical progression, developing discharge plans, presenting cases in rounds, and addressing clinical variances.
        • Collaborates with physician, interdisciplinary team and patient/family to develop comprehensive, proactive discharge plans for all complex patients.
        • Advises the physician and patient/family about options and plans for discharge.
        • Aware of clinical resource utilization and the financial impact to overall cost of care. Discusses options with physician.
        • Discusses resource utilization concerns and options with physician(s).
        • Participates and/or facilitates patient/family conferences to address clinical management issues and discharge plan.
        • Teaches patient/family regarding complex diseases and/or discharge instructions.

      • Coordination
        • Coordinates with the care team to ensure a smooth and efficient transition to home or post-acute services.
        • Coordinates communications between multiple physicians (attending & consulting), and shares pertinent information with the other clinic health coaches and healthcare team.
        • Advocates for the patient/family by assisting them in navigating through the healthcare and payer systems.

    • Essential Functions II

      • Participates in mandatory in-services and/or CE programs as mandated by policies and procedures/external agencies and as directed by management.

      • Follows and understands the mission, vision, core values, Employee Standards of Behavior and company policies/procedures.

      • Other duties as assigned.











Job Details

Date Posted January 2, 2019
Date Closes March 3, 2019
Requisition 11895
Located In Omaha, NE
Work At Physicians Clinic Inc
Department Medical Home
Shift Daytime
Hours Days hours per week
SOC Category 00-0000.00
Location