Transition Nurse Navigator Transitional Clinic

The Comprehensive CARE Center is a transitional clinic that bridges the gap between discharge and community.  The Transitional Nurse Navigator (TNN) follow patients that have recently discharged with a high risk diagnosis (CHF COPD Sepsis).  Under general direction this role is accountable for the highrisk patient population.  Ensures the continuity and coordination of patient care delivery by assessing patient needs; developing transitional care plans; identifies and leverages appropriate resources; and evaluates patient progress. Communicates patient care updates and other relevant information to all stakeholders in a timely and reliable manner. Under general direction this role is accountable for the highrisk patient population.  Ensures the continuity and coordination of patient care delivery by assessing patient needs; developing transitional care plans; identifies and leverages appropriate resources; and evaluates patient progress. Communicates patient care updates and other relevant information to all stakeholders in a timely and reliable manner.

• Identifies high risk patients through use of prospective risk stratification tool (e.g. high risk diagnosis START LACE etc.)
• Completes comprehensive psychosocial assessments consultation treatment and discharge recommendations to include remote patient monitoring
• Provides complex care planning to highrisk patients in the community via telephone calls inperson meetings telehealth etc. according to established program protocols and policies
• Accepts responsibility for patients Transitions of Care coordinating provisions for discharge from facilities including followup appointments home health community services transportation etc. in order to maintain continuity of care
• Coordinates and facilitates communications between all patient settings including acute care ambulatory short stay skilled nursing palliative care and hospice
• Promotes patient selfmanagement educating patients on disease specific needs medication access to care selfcare support to improve clinical outcomes and increase patient selfefficacy
• Identifies pts needs and makes appropriate referrals to programs/services (i.e. social worker pharmacist community agencies etc.)
• Consults regularly with the inpatient team PCP supervisor transitional team and other team members to ensure that the transition plan remains relevant appropriate and achievable to changing patient status and/or goals
• Meets with patients while in the hospital to establish rapport and smooth transition to outpatient setting and followup
• Maintains effective relationships with patients and families communitybased agencies and payers facilitating interdisciplinary team meetings
• Collaborates and implements plans in accordance with established policies prioritizing patient care goals and needs. Meeting with patients patients family and caregivers as needed to discuss transitional care and treatment plan
• Works proactively with patients caregivers and patients care team to identify an advanced care plan including Advanced Directives and MOLST
• Implements plan of care for the patient by performing evidencebased interventions and treatments specific to the diagnosis or problem of the patient; administers treatment such as lab draws start IVs injections nebulizer treatments wound care as directed by provider and monitors patients according to their needs and acuity level.  Performs symptombased standing orders and plan of care
• Maintains accurate and complete records initiates and oversees data entry into IT systems documents all care rendered pertinent patient information all communications and all care management decisions in appropriate database/electronic record
• Takes the lead on programs identifying improvements and putting changes in place to better assist the highrisk population.   Provides education to the team on information that will benefit patient outcomes
• Perform all other duties as assigned.
• Identifies high risk patients through use of prospective risk stratification tool (e.g. high risk diagnosis START LACE etc.)
• Completes comprehensive psychosocial assessments consultation treatment and discharge recommendations to include remote patient monitoring
• Provides complex care planning to highrisk patients in the community via telephone calls inperson meetings telehealth etc. according to established program protocols and policies
• Accepts responsibility for patients Transitions of Care coordinating provisions for discharge from facilities including followup appointments home health community services transportation etc. in order to maintain continuity of care
• Coordinates and facilitates communications between all patient settings including acute care ambulatory short stay skilled nursing palliative care and hospice
• Promotes patient selfmanagement educating patients on disease specific needs medication access to care selfcare support to improve clinical outcomes and increase patient selfefficacy
• Identifies pts needs and makes appropriate referrals to programs/services (i.e. social worker pharmacist community agencies etc.)
• Consults regularly with the inpatient team PCP supervisor transitional team and other team members to ensure that the transition plan remains relevant appropriate and achievable to changing patient status and/or goals
• Meets with patients while in the hospital to establish rapport and smooth transition to outpatient setting and followup
• Maintains effective relationships with patients and families communitybased agencies and payers facilitating interdisciplinary team meetings
• Collaborates and implements plans in accordance with established policies prioritizing patient care goals and needs. Meeting with patients patients family and caregivers as needed to discuss transitional care and treatment plan
• Works proactively with patients caregivers and patients care team to identify an advanced care plan including Advanced Directives and MOLST
• Implements plan of care for the patient by performing evidencebased interventions and treatments specific to the diagnosis or problem of the patient; administers treatment such as lab draws start IVs injections nebulizer treatments wound care as directed by provider and monitors patients according to their needs and acuity level.  Performs symptombased standing orders and plan of care
• Maintains accurate and complete records initiates and oversees data entry into IT systems documents all care rendered pertinent patient information all communications and all care management decisions in appropriate database/electronic record
• Takes the lead on programs identifying improvements and putting changes in place to better assist the highrisk population.   Provides education to the team on information that will benefit patient outcomes
• Perform all other duties as assigned.

Qualifications :

Education & Experience Required

• Associate Degree in Nursing required
• Minimum three (3) years of previous nursing experience required
• One (1) year previous case management experience
• Current Maryland RN license required
• BLS required

Education & Experience Preferred

• Experience with qualitybased reimbursement models utilization management or outpatient medical practice preferred

• Bachelor of Science in Nursing preferred

Knowledge Skills & Abilities

• Effective critical thinking skills both written and oral
• Facilitating patient access to community resources
• Possess working knowledge of discharge planning concepts including guidelines associated with Medicare Medicaid acute postacute and skilled home care
• Ability to communicate and collaborate effectively with both internal and external customers
• Assess adapt and calmly respond to changing and/or crisis environment
• Make independent decisions consistent with current policies procedures and ethical standards
• Prioritize work assignments and manage time effectively to complete duties
• Assist in data analysis and computer literate in word processing Excel and data management skills

Additional Information :

All your information will be kept confidential according to EEO guidelines.

Compensation:

Pay Range: $40.61$60.96

Other Compensation (if applicable):

Review theUMMS Benefits Guide