Registered Nurse Navigator Population Health Senior

DescriptionSummary: The RN Navigator is a member of the patient's care team and acts as a patient advocate providing proactive outreach to patients with chronic illness for the duration of their chronic care condition. The RN Navigator facilitates communication and coordinates care with physicians, the providers' clinic, hospital facilities, family, caregivers and other community healthcare providers and implements creative to meet members/ healthcare needs without compromising quality of outcomes. The RN Navigator will identify and enroll patients with chronic health conditions and/or refer to other programs as appropriate. The RN Navigator will support transitions of care as assigned and/or chronic condition support or health/wellness programs for the assigned population. The position responsibilities also include supporting health risk reduction through goal setting, behavioral change, patient education, and identification of social determinants with appropriate community referrals. In addition, the RN Navigator focuses on reducing preventable admissions, readmissions, and preventable ED visits by supporting discharge planning to the next level of care and educating patients regarding the appropriate setting for care. The RN Navigator connects the patient to health care providers and community resources to ensure ongoing quality of care. The nurse also promotes optimal person-centered care that supports and empowers individuals, respects individual choices and meets health care needs of patients. Develops relationships with and facilitates referrals to community resources including Skilled Nursing Facility (SNF), Rehab, Long Term Acute Care (LTAC), Home Health, Hospice, Palliative Care, Transportation, Medication Asst., DME, and other community resourcesReceives and evaluates HH 485 form (Plan of Care) based on Medical Necessity guidelines and Homebound Status requirements.Facilitates Case Conferences with HH Agency for evaluation of patient progress toward goals and discharge plan.Ensures HH agency is addressing the problem list and providing appropriate follow up for patient needs.Based on CMS or other payer guidelines, patient assessment, and case conferences, makes recommendation to PCP re: HH recertification or discharge from service.Creates positive relationships with HH agencies as well as Primary Care Clinicians and Office Staff.Ensures smooth transition of care along the continuum.Facilitates communication between HH agency and PCP practice as necessary to ensure patient's needs are addressed.Stays abreast of current CMS and other payer guidelines for HH services.Demonstrates expertise in navigating electronic medical record and other care management applications.Utilizes MCG Guidelines for Home Care to optimize the type, frequency, and duration of care.Monitors key measures of program success and provides feedback re: opportunities to improve. Requirements: BSN Preferred3-5 years acute care/clinical experience; 2-3 years managed care and/or care management experience; experience with high level communication; ability to lead interdisciplinary teams; ability to serve as a patient advocateTexas RN License Required Work Type: Full Time EEO is the law - click below for more information:  https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12ScreenRdr.pdf We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact us at (844) 257-6925. Additional Information: - Specialty: RN - Location: 5101 North O Connor BoulevardIrving, Texas 75039 - Contact: About the Company: CHRISTUS Health is an international Catholic, faith-based, not-for-profit health system comprised of more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. Sponsored by the Sisters of Charity of the Incarnate Word in Houston and San Antonio and the Sisters of the Holy Family of Nazareth, the mission of CHRISTUS Health is to extend the healing ministry of Jesus Christ. To support our healthcare ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on staff who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States. EXTENDING THE HEALING MINISTRY OF JESUS CHRIST We are inspired by our mission, vision and core values to deliver compassionate, high quality health care, improving the health of the communities we serve. Above all, we are committed to providing our customers and their family members with a truly unique healing experience, one that embodies our values and respects the dignity and worth of each person. Creating a health care system that is truly excellent in all areas is an ongoing effort.