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Job Summary:

The Disease Specific Navigator coordinates the care of, and provides education to, defined patient populations to ensure evidence-based clinical care, promote patient self-management, and achieve optimal clinical outcomes. This position participates in and supports process improvement initiatives to achieve evidence-based care and organizational goals. The Disease Specific Navigator collaborates with clinical leadership and healthcare providers across the care continuum to ensure patient and program needs are met.

Essential Functions & Responsibilities:

Coordinates the care of the inpatient to include:

i)Identification of patient/family readmission risk factors and barriers to care ii)Adherence to evidence-based clinical guidelines

iii)Resource utilization

iv)Development of an individualized plan of care to include appropriate referrals v)Development of a transitional/post-discharge plan of care to reduce risk of readmission

vi)Communication of relevant patient and plan of care information across the care continuum

Supports Inpatient to Outpatient medication reconciliation.

Facilitates fluid transfer of care from Inpatient to Outpatient providers/navigators.

Provides/reinforces disease-specific education to patients, families, and caregivers to support patient self-management and achieve optimal clinical outcomes.

Participates in disease specific meetings, eg, Readmission, Mortality.

Analyzes and identifies readmission trends through chart review, patient/family interview and staff engagement, and develops processes to reduce readmission.

Collaborates with leaders, physicians, nurses, allied health professionals, and support staff across the care continuum to ensure disease-specific patient and program needs are met and facilitates improvement of outcomes.

Develops and implements protocol and processes to support provision of evidence-based care in a defined patient population.

Develops disease-specific educational material and trains Associates involved in the care of defined patient population.

Actively participates in meetings and other care initiatives that support management of defined patient population.

Participates in regulatory reviews, as requested, to support hospital survey and/or disease-specific certifications.

Maintains competency of current evidence-based clinical guidelines for care of defined patient population through avenues such as self-education, attendance of conferences and participation in local/national networks.

Performs other duties as assign.

Qualifications:

Registered Nurse licensed to practice in the state of Virginia OR Licensed Respiratory Care Practitioner in good standing with the Commonwealth of Virginia is required.Associates Degree in Nursing OR Respiratory Care is required. Bachelors Degree in Nursing or Respiratory Care is preferred.Minimum of five years clinical experience in acute care or ambulatory care settingExperience with the defined patient population required.  This includes the ability to design educational tools and conduct educational sessions with patients and nursing staff.Experience in case management (or CCM certification), discharge planning, home care and/or utilization management is preferred.Experience with electronic health records and computer proficiency with applications such as MS Word, Excel, and Access is preferred.Demonstrated ability to work collaboratively with physicians and other healthcare providers in a professional manner.Strong assessment, verbal and written communication skills, and organizational/time management skills.Must be able to work autonomously, prioritize daily tasks and caseload activities to meet patient needs and turnaround times.Must be comfortable with process changes and able to reprioritize goals.Must possess solid listening skills and empathetic personality and demonstrate ability to utilize intuitive skills to engage diverse patient populations.

As an EOE/AA employer, the organization will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status.