Patient Care Navigator MSW, Transitions of Care

Hourly Pay Range

$32.60 - $48.90 - The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.

• Position:
  Patient Care Navigator-MSW
• Location:
  
  Warrenville, IL
• Full Time: 40 hours
• Hours:
  
  Monday-Friday, 8:30a-5:00p, 2 days onsite required and 3 days remote optional. Weekend and holiday required per rotation. Remote optional for weekend and holiday coverage.

The SW Care Navigator is responsible for the case management and care coordination of his/her population of patients from the time of diagnosis (could be pre-admission or in the ED) to 90 days post-discharge. This position will collaborate with the RN Care Navigator.

This position involves helping patients understand their diagnosis, treatment options, and ensure that they are connected with the optimal resources across the continuum of care. The SW Care Navigator will help to identify and address complex family dynamics and other social determinants of health. This role will coordinate discharge planning by facilitating smooth transitions of care while ensuring quality cost-effective patient outcomes.

Serves as a liaison between their patient population and all other providers.

Will be responsible for key metrics of success, which include improving the overall cost of care, length of stay optimization, reduction in excess days, reduction in SNF utilization and improvement in SNF care transitions, reduction in 30-day readmission rate and ED utilization.

• Connects with patient at the time of diagnosis (either ED or pre-admission) and follows the patient across the hospital stay and 90 days post discharge. Guides patient and family through the health system from diagnosis, testing, treatment and follow-up care to assist patients with navigating the continuum of care. Eliminates barriers to patient's access to health care services and facilitates continuity of care/care coordination.
• Partners with the healthcare team to ensure clinical decision-making, implementation of recommendations, and discharge planning are timely and appropriate.
• Oversees and facilitates effective and impactful interdisciplinary rounds that are structured and standardized.
• Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas.
• Performs daily coordination between multiple departments, multi-disciplinary team, medical clinics, and community outreach to gain knowledge of patient, assure patient safety, smooth transitions of care, and manage utilization and total cost of care.
• Routinely assesses and monitors the patient's status, needs, and progress by proactively reaching out to the patient/caregiver and ensuring that they are connected to the most appropriate and impactful resources.
• Acts as advisor/educator by providing emotional support including goals of care and counseling. Provides and/or arranges clinical education including medication management, community resources, financial resources, and expert guidance to patients and families to promote their ability to understand and meaningfully participate in the healthcare process and personal decision-making.
• Responsible for outreach efforts to establish and maintain positive working relationships with patients, family including multidisciplinary team i.e. physicians, office staff, diagnostic staff, nurses, social services staff, home services etc.
• Facilitates appointments for appropriate consultations and support services within established protocols
• May need to travel to visit the patient cts with providers across the care continuum proactively and in a timely way.
• Available to his/her assigned patient population 24/7 and participates as part of a call coverage structure.
• Participates in handoff processes within the team to ensure that patients are connected to the care navigator program across their care episode.
• Participates in the collection and analysis of data to identify under/over utilization; improve resource consumption; promote potential reduction in cost; and enhance quality of care consistent with organization strategic goals and objectives.
• Conducting…