Disease Navigator - Quality and Patient Safety; COPD Focus

Overview

Start the day excited to make a difference... end the day knowing you did. Come join our team.

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.

• Coordinates the care of the inpatient to include:

  • Identification of patient/family readmission risk factors and barriers to care
  • Adherence to evidence-based clinical guidelines
  • Resource utilization
  • Development of an individualized plan of care to include appropriate referrals
  • Development of a transitional/post-discharge plan of care to reduce risk of readmission
  • 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, e.g., 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 assigned.

• 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 setting.
• Experience 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.

Physical Requirements: Constant (67-100% of workday) use of arms and hands; frequent (34-66% of workday) standing, walking, and sitting; occasional (0-33% of workday) bending, stooping, and squatting; ability to lift 35 lbs.; ability to push and pull up to 20 lbs.; auditory and visual skills to include color determination.

Mental Requirements: Possesses critical thinking and analytical skills. Ability to multi-task. Ability to communicate effectively and collaborate with a multi-disciplinary team. Capacity to cope with difficult situations. Ability to tolerate irregular hours including evenings, nights, and weekends.

Environmental Requirements and Exposure Hazards: Potential risk of exposure to radiation and toxic chemicals. Potential for…