Spartanburg Regional Healthcare System
Spartanburg, SC, USA
The Nurse Navigator is a patient care manager r esponsible for overseeing the care coordination provided to patients transitioning from a hospital/rehab facility to home. Acts as a liaison between the physician, professional health care staff and other parties involved. Participates in assessing, planning, implementing, and evaluating health care services needed to prevent a hospital readmission. Responsible for linking patients with financial resources, educational materials, transportation services, and other community hospital and community based resources. Identifies and closes open quality measures to help meet annual CMS quality benchmarks. Participates in multidisciplinary conferences and acts as a patient
advocate working with the care team in communicating and solving patient issues. Must be flexible and adapt to changes in the work environment; change the approach or method to best fit the situation; be able to cope with delay or unexpected events. Takes responsibility; keep commitments; and complete tasks on time. Volunteer readily; take independent actions; ask for and offer help when needed.
Experience 5 years of experience in outpatient setting, population health, social services, home health, or other health care setting. Excellent written and verbal communication skills.
Valid US driver’s license with good driving record
Core Job Responsibilities
Actively manage high risk members including members with complex medical and/or psychosocial problems through care coordination including: closing care gaps, scheduling members for recommended follow-up, retrieving missing documentation, condition education, home/hospital visits and physician coordination.
Identify opportunities for intervention for each member.
Perform hospital and/or home visits for members within a designated time frame.
Coordinate with the team members on moderate/high risk members.
Develop a personalized care plan including self-management goals with each member, sharing each member’s self-management goals with the member’s care team including the member’s physician
Ensure the proper handling of patient records to ensure compliance with patient health information applicable to the preservation, accuracy, and completeness of communication and/or retention of patient information, meeting all HIPAA regulations and the HITECH Act provisions as required by law
Provide telephonic or face to face outreach to engage members to assess their readiness to change by using motivational interviewing techniques to help members identify and overcome barriers that often include behavioral risk factors, such as smoking, poor health literacy, sedentary lifestyle, elevated BMI, and poor disease management.
Proactively collaborate with providers, community resources, and other colleagues to help members achieve the best possible outcomes.
Must meet productivity standards set by direct manager.
Serve as a back-up to other nurses as needed
Provide clinical support, expertise and training, to Care Coordinators, Health Coaches, and other Nurses
Meet with the primary care providers and payers as needed to discuss quality, outcomes and clinical benchmarks for RHP contracts, documenting and reporting findings to management
Participate in Care Coordination meetings and provide other CarePlus members with support
Contributes to team effort by accomplishing results as needed
Achieves population health improvement goals
Properly documents all communication in accordance with policies and procedures
May perform other duties as assigned