POSITION SUMMARY:

To be fully engaged in providing Quality/No Harm, Customer Service and Stewardship by performing care management within the scope of licensure for patients with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans and disease specific education designed to optimize patient health care across the care continuum. Transitional Care Navigators work within a defined patient population to promote the achievement of optimal clinical and resource outcomes. Transitional Care Navigators utilize independent clinical judgment and works collaboratively with the interdisciplinary team to promote quality of care through collaboration with all team members, patients, families and significant support personnel. Transitional Care Navigator serves as an educational resource for patients, care givers and staff members. This includes meeting with patients, bedside, at the patient’s home and/or telephonically. The will assist patients set realistic health goals and provide support in reaching those goals through education, care coordination, and support. Transitional Care Navigator performs overall coordination of care for identified patients via telephonically or on-site such as at hospitals, in-home, or various placements after discharge. This position has direct supervisory responsibilities for all the RN Transitional Care Navigators within the department (IDN wide, 4 hospitals)

PRIMARY ACCOUNTABILITIES:

Quality/No Harm:

• Completion of all Mid-year and annual evaluations of all RN Transitional Care Navigators within the department (IDN wide, includes all 4 hospitals).
• Scheduling of all RN Transitional care Navigators to ensure 7 days a week coverage across the IDN.
• Schedules and facilitates individual and team meetings with all RN Transitional Care Navigators within the IDN (frequency based on needs of team and individuals,) minimum on a monthly basis.
• Timekeeping and Kronos scheduling/approval for direct reports.
• The Transitional Care Navigator plans effectively to meet patient needs during their hospital stay regarding processing them through the system and managing the length of stay, promoting efficient utilization of resources, and plans for a safe discharge continually evaluating and updating patient status. Specific functions within this role include: o Facilitation of patient’s transitional plan in collaboration with the physician, nursing and interdisciplinary team. o Facilitation of the collaborative management of patient care across the continuum, intervening as necessary to remove and escalate barriers to timely and efficient care delivery. o Application of process improvement methodologies in evaluating outcomes of care. o Identifies at-risk populations using approved screening tool and follows established referral processes for patients. o Promotes professional practice through collegial support and interactions. o Practices autonomously, consistent with evidence-based standards. o Using identified reports, works collaboratively with Care Transitions team to identify high risk patients and assure safe transition to the next level of care to prevent readmissions. o Utilize motivational interviewing and engagement strategies to support overall health, wellness of patients and self-management which includes employing behavior change/motivational interviewing skills to assess readiness, health goal setting short and/or long term needs, engage patient's plans for change following standard policy and procedures, clinical guidelines and national evidenced-based criteria. o Document interactions and interventions as directed with health technology, risk stratification and patient engagement tools.

Stewardship:

• Provides health coaching activities across the continuum of care in order to facilitate and promote high quality, cost-effective outcomes, focused on the whole patient orientation and self- management decision support and aims to minimize any fragmentation of health care delivery.
• Supports system-wide efforts pertaining to alternative payment models and reductions in Medicare Spending (MSPB).
• Identify cost savings options for patients.
• Addresses/resolves system problems impeding diagnostic or treatment progress.
• Proactively identifies resolves or escalates delays and obstacles.
• Demonstrates understanding of level of care criteria and reimbursement factors for home care, rehabilitation, outpatient treatment, residential treatment and long term care in development of discharge plans. Seeks alternatives to discharge planning, and creates relationships with all supportive organization to help in the discharge process.

Customer Experience:

• Demonstrates positive customer relations in all settings and circumstances.
• Demonstrates strong I-CARE values.
• Possess strong empathy skills and able to develop strong rapport with patients.
• Demonstrates effective communication with other members of the healthcare team and promotes effective team functioning.
• Provides patient, family, and/or caregiver education as directed by the plan of care.
• Provides service to patients and families with sensitivity and respect for their needs, expectations, age, cultural, and individual differences.
• Works with the physician advisor, physicians, nursing, ambulatory programs, outpatient programs, interdisciplinary team and health plan for defined patient populations to develop clinical appropriate transitional pathways, continuum care management for patient care and patient satisfaction.
• Coordinates/facilitates patient care progression. Review discharge needs at time of admission, and assists with the transition of care through hospital say and discharge.
• Works collaboratively and maintains active communication with physicians, nursing, physician advisor, and other members of the interdisciplinary care team to effect timely, appropriate patient resource management, and patient transition.
• Seeks consultation from appropriate disciplines/ancillary departments as required to expedite care and facilitate patient transition.
• Demonstrates positive customer relations in all settings and circumstances.
• Promotes patient's independence by establishing patient care goals; teaching and counseling patient, friends, and family and reinforcing their understanding of disease, medications, and self-care skills.
• Provides information to patients and health care team by answering questions and requests.
• Resolves patient needs by utilizing multidisciplinary team strategies.

QUALIFICATIONS REQUIRED:

• Bachelor of Science Nursing required or Associate Degree with 10 years of clinical experience.
• Prior leadership or supervisory experience in a healthcare setting (3-5 years).
• Current valid license to practice as a Registered Nurse in the State of Florida.

Knowledge/Skills/Abilities:

• Community education and public speaking experience.
• Must have demonstrated leadership skills.
• Conceptual and applied expertise in chronic and patient-centered care models; experience with managed care models and community health programs strongly preferred.
• Engagement in national trends within patient engagement, activation and self management.
• Demonstrated ability to negotiate diverse relationships and forge alliances in conditions of ambiguity and complexity.
• Sound communication and organizational skills; LEAN certification preferred.
• Knowledge of managed care concepts, health promotion/disease management strategies, and trans theoretical model.
• Knowledge of general healthcare practices, office workflows and medical terminology.
• Ability to develop health education materials and tailor information at the appropriate level of literacy.
• Strong verbal and written communication skills and ability to apply motivational interviewing techniques.
• Strong organizational and prioritization skills.
• Experience conducting educational and support groups.
• Knowledge of specific disease and lifestyle related topics such as weight management, tobacco cessation, chronic conditions (CHF, diabetes, COPD) and stress management.
• Knowledge of community health and social service agencies and additional community resources.
• Positive role model in demonstrating healthy behaviors.
• Working knowledge of wellness programming and individual engagement strategies.
• Thorough knowledge and understanding of behavior change theories and their application.
• Strong proficiency in Windows-based database applications.
• Ability to work independently and prioritize a heavy workload with minimal supervision.
• Ability to work with patients to develop health enhancement strategies to improve health outcomes and self-management.
• Exceptional problem solving skills and adept at conflict resolution.
• Strong customer service skills and ability to function among a high performing team.
• Ability to communicate in a timely manner with all stakeholders.

PHYSICAL DEMANDS:

• Ability to adapt to changes in the workload and work schedule as well as the ability to travel among various entities.
• Repetitive use of hands and fingers to enable computer use.
• Good eyesight to read labels/prescriptions, graduated instruments.
• Good hearing and listening skills.
• Potential for exposure to biohazardous materials, and know or unknown disease.
• Handle large volumes of work for long periods of time.
• Walk, bend, stoop, twist, sit, and stand for long periods of time for 8-10 hours per day.
• May require lifting and carrying light loads (up to 40 pounds).

MENTAL DEMANDS:

• Ability to manage multiple projects and priorities.
• Ability to adjust approach to work in response to changing situations to achieve goals.
• Must have ability to concentrate on multiple priority activities.
• Ability to respond and make decisions quickly.
• Ability to handle service issues in a timely and professional manner.
• High degree of self-knowledge and emotional intelligence.
• Ability to handle multiple tasks, often within time constraints.
• Ability to quickly assess needs and make decisive decisions.
• Ability to speak in front of groups, taking into account ethnicity and cultural backgrounds.
• Maintain confidentiality of patients and organizational issue.

Job: *Clinical Professional

Organization: *Health First Shared Svcs Inc

Title: Supervisor RN Transitional Care - Care Continuum Community Health

Location: Florida - Brevard County-Rockledge

Requisition ID: 072846