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Status (FT/PT): Full-Time
Shift: Day shift
Req ID: 55552
$10,000 Sign-On Bonus
Munson Healthcare - Grayling North Campus Clinic
1100 E Michigan Ave
Full Time / Day Shift / Monday - Friday
No nights, weekends or holidays!
WHAT YOU WILL DO IN THIS ROLE:
As a Nurse Navigator you will act as a liaison between patients, professional staff and physicians by providing care management and care coordination for adult and pediatric patients, with complex conditions, with complex social needs, and education needs.
Serves in an expanded health care role to collaborate with primary care providers, specialists, members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services.
Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient’s health status and decreasing hospital and emergency room utilization.
Integrates evidence-based clinical guidelines and protocols, in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care.
WHAT WE ARE SEEKING IN YOU FOR THIS ROLE:
Currently licensed as a Registered Nurse in the State of Michigan.
Bachelor of Science degree in nursing preferred.
At least 4 years of nursing experience in an ambulatory setting preferred.
Demonstrates a high-level understanding of complex chronic disease management.
Has the ability to assess patient needs, make appropriate referrals face to face or via telephone as indicated for ancillary support services and programs.
Is a self-directed professional with the ability to make independent judgments directing patient care.
Possesses exceptional problem solving with the ability to organize, identify, change priorities and be flexible in decisions.
Demonstrated clinical competence and ownership of practice.
Effective written and oral communication skills in person, via phone and on the computer.
Demonstrates participation in organizational and / or CFCC based process improvements.
Works with team to identify the targeted high-risk population within practice site(s) per population health risk stratification process and discharge lists. Includes patients with repeated social and/or health crisis.
Assesses over time the health care, educational, and psychosocial needs of the patient/family. Uses standardized assessment tools such as depression screening, functionality, and health risk assessment.
Collaborates with primary care provider, patient, and members of the health care team, including continuum of care settings and community. Responsible for developing a comprehensive individualized plan of care and targeted interventions. Continually monitors patient/family response to plan of care, and revises the care plan as indicated, during the transition period (including 30 days post discharge).
Provides patient self-management support with a focus on empowering the patient/family to build capacity for self- care.
Implements systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations.
Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
Coordinates patient care through ongoing collaboration with primary care provider, patient/family, community, and other members of the health care team. Fosters a team approach and includes patient/family as active members of the team. Takes the lead in ensuring the continuity of care, which extends beyond the practice boundaries. Serves as liaison to acute care hospitals, specialists, and post-acute care services.
Provides follow-up with high-risk patient/family when patient transitions from one setting to another. Completes timely post-hospital follow-up: medication reconciliation, primary care provider or specialist follow-up appointment, assess symptoms, teach warning signs, review discharge instructions, coordination of care, and problem solve barriers.
Demonstrates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills.
Maintains required documentation and billing for all care management activities based on federal and state billing guidelines.
Works with hospital, practice and Physician Organization/Physician Hospital Organization leadership to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance care management and Patient Centered Medical Home delivery of care model.
Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates into clinical practice.
Other duties as assigned.
HOW THIS ROLE FITS INTO THE ORGANIZATION:
Accountable to the Manager or designee of the assigned department.
Provides direction to and supervision of LPNs, MA’s. Techs, Clerks, Nursing Assistants, and/or other categories as needed.
Works collaboratively and effectively with all members of the specialty team, including care providers and staff and is a liaison with other departments/units, hospitals within MHC system and academic centers (when applicable).
PROFESSIONAL PERFORMANCE STANDARDS
Quality of Care and Leadership Practice