Patient Care Navigator, LPN – JACKSON, TN

Description

General Summary: A non-exempt position responsible for utilizing the nursing process to provide optimal quality and continuity of nursing care from the pre-operative setting through a 90 day episode of care. The Patient Care Navigator will implement care plans that are specific to each patient’s physical, mental and social needs, based on pre-surgical clinical assessments. The care plans will be implemented and modified, as needed throughout the transition of care to ensure the patient’s well-being and achievement of the desired outcomes. The Patient Care Navigator will work collaboratively as part of a multi-disciplinary team to provide patient and family education, communicate with healthcare providers and coordination and facilitation of services within an episode of care.

Position: Full-Time

Hours: M-F, 8a-5a

Essential Job Responsibilities:

1. Managing a group of Medicare orthopedic population throughout of 90 day episode of care, as part of the Bundled Payments for Care Improvement-Advanced Initiative.
2. Gather clinical information from the EMR and telephonic health assessments to determine risk stratification including a comprehensive assessment of physical, emotional, psychosocial, and environmental needs of the patient.
3. Document clinical assessments and care plans in designated case management system.
4. Educate the patient and caregiver of the process and expectations of the health care delivery system throughout the course of care, AR, SNF, LTAC, Home Care.
5. Development and implementation of care plans throughout the transition of care to ensure the patients well-being.
6. Collaborate with multidisciplinary team members in the acute, post-acute and outpatient settings to identify patient needs such as home health care, DME, physical therapy and community services.
7. Follow up on patients at pre-determined intervals and as needed based on patient status, telephonic and on-site.
8. Complete and submit all required documentation within established guidelines.
9. Evaluate plan of care and revise on an ongoing basis as determined by patient’s health status and communicate changes to all other disciplines involved in the patient’s care.
10. Communicate with providers and multi-disciplinary care team members to facilitate transition of services throughout the continuum of care.
11. Identify gaps or barriers in treatment plans to ensure that discharged patients receive appropriate resources and services.
12. Understand the Bundled Payment Program design, implementation, management, monitoring and reporting requirements.
13. Remain flexible and responsive when changes occur in patient activity and workload.

Education: Licensed Practical Nurse required.

Experience: Minimum of 2-3 years of nursing experience in a hospital setting or case management required. Medicare or Medicare Advantage experience preferred.

Download Application or apply online below.