Company: Spartanburg Regional Healthcare System
Posted on: December 5, 2019
The Nurse Navigator is a patient care manager responsible 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
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
- 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
- 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
- Achieves population health improvement goals
- Properly documents all communication in accordance with
policies and procedures
- May perform other duties as assigned
Keywords: Spartanburg Regional Healthcare System, Spartanburg , Nurse Navigator, Healthcare , Spartanburg, South Carolina
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