Patient Care Navigator, LPN – JACKSON, TN

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

• 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.
• 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.
• Document clinical assessments and care plans in designated case management system.
• 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.
• Development and implementation of care plans throughout the transition of care to ensure the patients well-being.
• 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.
• Follow up on patients at pre-determined intervals and as needed based on patient status, telephonic and on-site.
• Complete and submit all required documentation within established guidelines.
• 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.
• Communicate with providers and multi-disciplinary care team members to facilitate transition of services throughout the continuum of care.
• Identify gaps or barriers in treatment plans to ensure that discharged patients receive appropriate resources and services.
• Understand the Bundled Payment Program design, implementation, management, monitoring and reporting requirements.
• 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.