Work whereevery momentmattersEvery day almost Hartford HealthCare employees come to work with one thing in common Pride in what we do knowing every moment matters here We invite you to become part of Connecticutrsquos most comprehensive healthcare networkHartford Hospital is one of the largest and most respected teaching hospitals inNew England We are a Level Trauma Center that provides cutting edge treatment to its patients This is made possible by being home to the largest robotic surgery center in the Northeast and the Center for Education Simulation and Innovation CESI one of the most advanced medical simulation training centers in the world When hospitals cannot provide the advanced care expertise and new treatment options for their patients require they turn to usThe Center for Transitional Care is located at Retreat Ave on thesecond floor of the Brownstone Specialty Clinic Building This clinic was developed to reduce readmissions and prevent gaps in care in addition to reducing adverse outcomes to the patients leaving Hartford Hospital without a Primary Care Provider A Nurse Navigator performs transitional outreach after hospital discharge and the clinic staff supports the patients for the day post hospital discharge in connecting with Specialty and Primary careJob SummaryFunctioning within the context of the framework for professional nursing practice the Transitional Care Nurse Navigator is a registered nurse experienced in patient throughput preventing transitional care gaps and resolving issues to enhance the quality and continuity of a patientrsquos or population health care leading to improved health outcomes and equitable care This role supports the HHCmission to improve the health and healing of allJob ResponsibilitiesFunctions as a member of an inter professional care team in an expanded nurse role to help those patients without a primary care provider transition from the acute care setting HH ED or inpatient The goals include reducing all cause readmissions and inappropriate ED utilization improving care coordination for patients during the transitional care period and ultimately improving care quality and access for vulnerable populations This role will be responsible for educating the HH community at large and advocating for resources to enhance patient healthcare engagement and expand the collaboration and communication between inpatientambulatoryoutpatientattendingtransitional carespecialty careprimary care providers and care teams for high riskcomplex patientsPartners with the inpatient ie acute care IOL STR or ED physician and care team to proactively identify potential transitional care gaps for this patient population and establish a safe transition plan Key strategies include ensuring a patientcaregiver agreed upon Center for Transitional CareTransition Clinic and urgent specialists scheduled appointments with transportation verifying patient has necessary DME finalizing an achievable community medication plan completing diagnostic workup educating the patient on disease and symptom management and incorporating a patient centered home care planPerforms post hospitalizationED transitional care interventions within business hours after discharge including post discharge phone calls patient education symptom management and medication reconciliation and collaborates with transition clinic physician and clinic and community care team to minimize identified gaps in careThroughout the post inpatientED transitional care period facilitates the completion of the diagnostic workup follows up on unresulted diagnostics collaborates with homecare pharmacy and DME to ensure the patient has necessary suppliesmedicationsresources obtains necessary authorizations and schedules additional consultant appointmentsCollaborates with clinic physicians to resolve issues and to advance the treatment plan until the patient has an established primary care providerIn collaboration with the Transition Clinic physician assists the patient in identifying a primary care practice for continued care and facilitates the transfer of care to that practiceDocuments all communication transition plan implemented strategies and patient outcomes in EPICAs a member of the Center for Transitional CareTransition Clinic completes transitional care strategies and actions per CMSPayer guidelines for Transitional Care Management or other program directivesEstablishes a therapeutic rapport with patients and demonstrates a commitment to serve as a patient advocateDemonstrates the ability to work independently as well as collaboratively as a member of the health care team in order to provide safe patient care and prompt and efficient service The Transitional Care Nurse Navigator provides transitional care strategies to hisher peerscolleagues and patients based on needcoverageDue to the nature of this busy outpatient clinic the ability to multitask along with outstanding communication skills and reliable follow up is requiredAttendsLeads and actively participates in care team meetings to facilitate a safe transition plan or resolve a patient issueEstablishes evidence based standard work and workflows Develops and implements processes that improve the patient experience Collects and analyzes patient and program level data identifies areas of opportunity recommends improvementsrevisions or program development and leadsparticipates in the ideaplan implementationApplies the nursing process as appropriate within the context of the organizationrsquos framework for professional nursing practice and following guidelines established by the teamWork whereevery momentmattersEvery day almost Hartford HealthCare employees come to work with one thing in common Pride in what we do knowing every moment matters here We invite you to become part of Connecticutrsquos most comprehensive healthcare networkHartford Hospital is one of the largest and most respected teaching hospitals inNew England We are a Level Trauma Center that provides cutting edge treatment to its patients This is made possible by being home to the largest robotic surgery center in the Northeast and the Center for Education Simulation and Innovation CESI one of the most advanced medical simulation training centers in the world When hospitals cannot provide the advanced care expertise and new treatment options for their patients require they turn to usThe Center for Transitional Care is located at Retreat Ave on thesecond floor of the Brownstone Specialty Clinic Building This clinic was developed to reduce readmissions and prevent gaps in care in addition to reducing adverse outcomes to the patients leaving Hartford Hospital without a Primary Care Provider A Nurse Navigator performs transitional outreach after hospital discharge and the clinic staff supports the patients for the day post hospital discharge in connecting with Specialty and Primary careJob SummaryFunctioning within the context of the framework for professional nursing practice the Transitional Care Nurse Navigator is a registered nurse experienced in patient throughput preventing transitional care gaps and resolving issues to enhance the quality and continuity of a patientrsquos or population health care leading to improved health outcomes and equitable care This role supports the HHCmission to improve the health and healing of allJob ResponsibilitiesFunctions as a member of an inter professional care team in an expanded nurse role to help those patients without a primary care provider transition from the acute care setting HH ED or inpatient The goals include reducing all cause readmissions and inappropriate ED utilization improving care coordination for patients during the transitional care period and ultimately improving care quality and access for vulnerable populations This role will be responsible for educating the HH community at large and advocating for resources to enhance patient healthcare engagement and expand the collaboration and communication between inpatientambulatoryoutpatientattendingtransitional carespecialty careprimary care providers and care teams for high riskcomplex patientsPartners with the inpatient ie acute care IOL STR or ED physician and care team to proactively identify potential transitional care gaps for this patient population and establish a safe transition plan Key strategies include ensuring a patientcaregiver agreed upon Center for Transitional CareTransition Clinic and urgent specialists scheduled appointments with transportation verifying patient has necessary DME finalizing an achievable community medication plan completing diagnostic workup educating the patient on disease and symptom management and incorporating a patient centered home care planPerforms post hospitalizationED transitional care interventions within business hours after discharge including post discharge phone calls patient education symptom management and medication reconciliation and collaborates with transition clinic physician and clinic and community care team to minimize identified gaps in careThroughout the post inpatientED transitional care period facilitates the completion of the diagnostic workup follows up on unresulted diagnostics collaborates with homecare pharmacy and DME to ensure the patient has necessary suppliesmedicationsresources obtains necessary authorizations and schedules additional consultant appointmentsCollaborates with clinic physicians to resolve issues and to advance the treatment plan until the patient has an established primary care providerIn collaboration with the Transition Clinic physician assists the patient in identifying a primary care practice for continued care and facilitates the transfer of care to that practiceDocuments all communication transition plan implemented strategies and patient outcomes in EPICAs a member of the Center for Transitional CareTransition Clinic completes transitional care strategies and actions per CMSPayer guidelines for Transitional Care Management or other program directivesEstablishes a therapeutic rapport with patients and demonstrates a commitment to serve as a patient advocateDemonstrates the ability to work independently as well as collaboratively as a member of the health care team in order to provide safe patient care and prompt and efficient service The Transitional Care Nurse Navigator provides transitional care strategies to hisher peerscolleagues and patients based on needcoverageDue to the nature of this busy outpatient clinic the ability to multitask along with outstanding communication skills and reliable follow up is requiredAttendsLeads and actively participates in care team meetings to facilitate a safe transition plan or resolve a patient issueEstablishes evidence based standard work and workflows Develops and implements processes that improve the patient experience Collects and analyzes patient and program level data identifies areas of opportunity recommends improvementsrevisions or program development and leadsparticipates in the ideaplan implementationApplies the nursing process as appropriate within the context of the organizationrsquos framework for professional nursing practice and following guidelines established by the teamBachelorrsquos Degree required MSN preferredMinimum five years of nursing experience Inpatient and Ambulatory nursing experienceCurrent Connecticut Nursing LicenseBLS CertificationSpanish speaking verbal and written is strongly preferredWe take great care of careersWith locations around the state Hartford HealthCare offers exciting opportunities for career development and growth Here you are part of an organization on the cutting edge ndash helping to bring new technologies breakthrough treatments and community education to countless men women and children We know that a thriving organization starts with thriving employees we provide a competitive benefits program designed to ensure worklife balance Every moment matters And this isyour momentAs an Equal Opportunity EmployerAffirmative Action employer the organization will not discriminate in its employment practices due to an applicantrsquos race color religion sex sexual orientation gender identity national origin and veteran or disability statusBachelorrsquos Degree required MSN preferredMinimum five years of nursing experience Inpatient and Ambulatory nursing experienceCurrent Connecticut Nursing LicenseBLS CertificationSpanish speaking verbal and written is strongly preferredWe take great care of careersWith locations around the state Hartford HealthCare offers exciting opportunities for career development and growth Here you are part of an organization on the cutting edge ndash helping to bring new technologies breakthrough treatments and community education to countless men women and children We know that a thriving organization starts with thriving employees we provide a competitive benefits program designed to ensure worklife balance Every moment matters And this isyour momentAs an Equal Opportunity EmployerAffirmative Action employer the organization will not discriminate in its employment practices due to an applicantrsquos race color religion sex sexual orientation gender identity national origin and veteran or disability status