NURSE NAVIGATOR - ORTHOPEDICS, CASUAL

Job Summary

The Nurse Navigator functions on the multidisciplinary team as an advocate, interpreter, and educator for patients and significant others.  Responsible for ensuring all patients who are navigated receive quality and comprehensive services.  Coordinates patient care throughout the continuum in collaboration with the multidisciplinary team.  Serves as a liaison throughout the facility and in the community regarding services provided for this unique patient population. Serves as a single point of contact for referring physicians, patients, and caregivers to provide resources and assistance with accessing clinical and supportive care services offered within Excela Health and the community.

Participates in data analytics as it relates to utilization, quality, satisfaction and outcomes.

Essential Job Functions         

• Demonstrates the knowledge, skill and coordination to provide nursing care and guidance to patients from point of contact through recovery
• Systematically and continually performs the functions of assessing, planning, implementing, and evaluating the care of patients
• Maintains professional and technical knowledge by attending education workshops; reviewing professional publications; establishing personal networks; participating in professional societies.
• Assures quality of care by adhering to therapeutic standards; measuring health outcomes against patient care goals and standards; making or recommending necessary adjustments; following system/hospital and nursing division's philosophies and standards of care set by state board of nursing, state nurse practice act, and other governing agency regulations.
• Protects patients and employees by adhering to infection-control policies and protocols, medication administration and storage procedures, and controlled substance regulations.
• Documents patient care services by charting in patient and department records.
• Maintains continuity among nursing teams by documenting and communicating actions, irregularities, and continuing needs using Nurse Knowledge Exchange techniques.
• Maintains patient confidence and protects operations by keeping information confidential.
• Implements standard work, clinical protocols and patient care pathways.
• Ensures safe and effective transitions of care that help to promote positive health care outcomes for Excela Health patients.
• Functions as preceptor for new hires.
• Assesses, plans, implements coordinates, and monitors and evaluates options for patients, their families, caregivers and the health care team, including providers, to promote effective care coordination outcomes.
• Manages transitions of care effectively as one of the critical components to reducing readmissions and poor health outcomes. Provides crisis management for clients; makes linkages for interventions as appropriate.
• Initiates care coordination strategies that are evidence-based and outcome focused.
• Implements standard work, clinical protocols and patient care pathways.
• Identifies patient care requirements by establishing personal rapport with potential and actual patients, and other persons in a position to understand care requirements.
• Establishes a compassionate environment by providing emotional, psychological, and spiritual support to patients, friends, and families.
• Promotes patient's independence by establishing patient care goals; teaching patient/family to understand condition, medications, and self-care skills; answering questions.
• Maintains safe and clean working environment by complying with procedures, rules and regulations; calling for assistance from health care support personnel.
• Demonstrates competencies of clinical reasoning and critical-thinking skills for managing complex and high-risk patients while simultaneously assuming the patient advocate role to ensure conflict-free, unbiased and culturally competent care.
• Assures care coordination that takes into account patients' values, needs, preferences and their choice to self-direct care.
• Puts the patient at the center of all care decisions and is an essential driver to ensuring that patients get the right care, in the right setting, at the right time.
• Effectively manages transitions involving comprehensive planning, targeted outreach and the timely transfer of information between parties critical to the transition. Manages transitions of care effectively as one of the critical components to reducing re-admissions and poor health outcomes.
• Facilitates the flow of care to expedite appropriate discharge and prevent readmissions.
• Assumes the leadership role in achieving outcomes and making the health system work for the patient.
• Brings access, understanding and knowledge of the community and the resources to support management of chronic illness.
• Resolves patient problems and needs by utilizing multidisciplinary team strategies.
• Maintains a cooperative relationship among health care teams by communicating information; responding to requests; building rapport; participating in team continuous quality improvement and problem-solving methods.
• Contributes to team effort by accomplishing related results as needed.
• Implements effective care coordination strategies that are evidence-based and outcome focused.
• Seeks role as chair, co-chair, and lead for CQI projects or shared governance, council, committees or work groups.

Specialty Job Functions

• Responsible for educating patients at the Joint Works 1^st Step Classes.
• Develops patient education materials and utilizes technology, when available, to educate patients.
• Central point of contact for all navigated patients; including interaction with medical, nursing, and ancillary services.
• Serves as point of contact to all patients for identified patient population from point of contact through the continuum of care.
• Oversees the planning scheduling, and implementations of day-to-day clinical activities and procedures for navigated patients.
• For assigned patient population:
• Coordinates and communicates with providers
• Facilitates appointments for appropriate consultations and support services within established protocol
• Responds to patient requests for information
• Partners with patients, families, the interdisciplinary team, and community resources to provide well-coordinated, timely, compassionate, exemplary, interdisciplinary care.
• Monitors compliance with patient treatment plan thru the entire episode of care.
• Evaluates patient satisfaction with services offered including investigation of concerns / complaints.
• Functions in an organized and time conscious manner. Communicates with all members of the healthcare team, as appropriate about patient/family needs and concerns.
• Initiates and performs ongoing review of policies related to services provided. Where appropriate, updates or writes new policies to enhance professional practice.
• Serves as resource for community educational events, such as health fairs, screenings, symposiums, and lectures, as well as staff education.
• Coordinates / participates in multidisciplinary planning conferences.
• Develops concise patient summaries for use by the patient and care team utilizing standardized care protocols in accordance with nationally recognized care guidelines.
• Drafts quarterly report cards and presents to service line committees / workgroups to demonstrate outcomes and performance improvement activities.
• Responsible for outreach efforts to establish and maintain positive working relationships.
• Strives to achieve excellence of services.
• To the best of the employee’s knowledge and understanding, complies with all federal and state laws and regulations.
• Maintains the privacy and security of all confidential and protected health information. Uses and discloses only that information which is necessary to perform the function of the job.
• Performs miscellaneous job-related duties as assigned.
• Active participate on the Joint Works and other related committees.
• Accountable for participating in data analysis as it relates to utilization, participation and quality as it relates to program and within scope of job function.
• Works collaboratively with the Director of Rehab Services to accomplish the goals / objectives of the Joint Works program.
• Other related duties as assigned.

Required Qualifications

• Graduate of an accredited Nursing Program required.
• Master’s Degree in Nursing or related field (Health Administration, Business, Public Health, Management)
• Two years direct medical/surgical experience in and RN Case management, or care navigation experience within past five years.
• Strong leadership ability, independent thinking and decision-making ability; analytical problem solving skills, sound judgment; excellent oral and written communication skills, must be able to function in a team environment.
• Strong time management and organizational skills; ability to work independently and in a team setting; is able to multi-task and prioritize assignments and demonstrate excellent problem solving skills; creativity, and ability to transition smoothly to various settings including inpatient, skilled nursing, physician office and outpatient clinics; flexibility in scheduling.
• Working knowledge: PC and Related Software (Microsoft Office)

Preferred Qualifications

• Two (2) years’ experience in hospital, ambulatory, or office setting for patient population responsible for managing.
• Knowledge of Payor / Insurance benefits

License, Certification & Clearances

• Current licensure to practice as a Registered Nurse in the State of Pennsylvania required.
• Current Basic Life Support (BLS) approved curriculum of the American Heart Association (CPR and AED) program required.
• Nursing Specialty Certification within 2 years of eligibility or hire e.g. Ambulatory Care Nurse or Care Coordination and Transition Management.
• PA Act 153 Clearances (Act 34-PA Criminal Record Check from the PA State Police system, Act 33-PA Child Abuse History obtained through the Department of Public Welfare, Act 73-FBI Fingerprint screening within 2 weeks of hire in order to meet 30 days of hire or transfer position requirement).

Supervisory Responsibilities

• This position has no direct supervisory responsibilities, but may serve as a coach and mentor for other positions in the department.

Position Type/Expected Hours of Work

• Incumbent will be scheduled based on operational need (rotate shifts, standby, on-call, etc.).
• Travel may be expected locally between Excela Health locations.

LEAN

• Actively promotes a Lean work culture by performing team member duties to encourage consistent use of LEAN principles and processes, including continually seeking work process improvements. Recognizes the necessity of taking ownership of one’s own motivation, morale, performance and professional development. Strives for behavior consistent with being committed to Excela’s missions, vision and values.

AAP/EEO 

• Excela Health is an Equal Opportunity Employer. It is the policy of Excela Health to prohibit discrimination of any type and to afford equal employment opportunities to employees and applicants, without regard to race, color, religion, sex, national origin, age, marital status, non-job related disability, veteran status, or genetic information, or any other protected class. Excela Health will conform to the spirit as well as the letter of all applicable laws and regulations.
• Ability to perform the Essential Functions listed on the Physical Conditions and ability to perform the Essential Functions on the Working Condition chart below.

Work Environment

Physical Demands