*POSITION SUMMARY:* 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, caregivers 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. 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. *PRIMARY ACCOUNTABILITIES: * *Quality/No Harm: * * Facilitation of patient’s transitional plan in collaboration with the physician, nursing and interdisciplinary team. * 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. * Application of process improvement methodologies in evaluating outcomes of care. * Identifies at-risk populations using approved screening tool and follows established referral processes for patients. * Promotes professional practice through collegial support and interactions. * Practices autonomously, consistent with evidence-based standards. * 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. * 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. * Document interactions and interventions as directed with health technology, risk stratification and patient engagement tools. *Stewardship: * * 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. *QUALIFICATIONS REQUIRED:* * Current valid license to practice as a Registered Nurse in the State of Florida. * Bachelor of Science Nursing required or Associate Degree with 7-10 years of clinical experience. * Three or more years’ strong clinical experience in clinical practice area. * Excellent interpersonal communication and negotiation skills. * Community education and public speaking experience preferred. * Knowledge of managed care concepts, health promotion/disease management strategies, and trans theoretical model Strong analytical, data management and PC skills. * Current working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement preferred. * Understanding of pre-acute and post-acute venues of care and post-acute community resources. * Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. * Ability to work independently and exercise sound judgment in interactions with physicians, patients and their families. * Performs duties in a manner to promote quality patient care and customer service/satisfaction, while promoting safety, cost efficiency, and a commitment to the process improvement process. * Excellent writing and presentation skills. *PHYSICAL DEMANDS*: * Must be able to sit or stand minimum of eight hours per day using telephone and computer. * Ability to effectively communicate with all members of the healthcare team and function as an advocate for the member. * Ability to work extended hours to see issues through to resolution for the member. * Good eyesight to read labels/prescriptions, graduated instruments. * Good hearing and listening skills. * Potential for exposure to biohazardous materials, and known or unknown diseases. * 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: * * Must demonstrate critical thinking skills in all aspects of work performed, and demonstrates an ability to be flexible, organized and functional under stressful situations. * Ability to manage multiple projects and priorities. * Ability to assimilate, assess and act upon new concepts/trends. * Ability to adjusts 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. * Ability to work independently and prioritize a heavy workload with minimal supervision. **Job:** **Clerical Support* **Organization:** **Health First Shared Svcs Inc* **Title:** *RN Transitional Care Navigator - Care Continuum Community Health* **Location:** *Florida - Brevard County-Melbourne* **Requisition ID:** *076372*