Rn Navigator, Community Jobs

Department: 78007328 Senior Care Transitions Complex Care
Shift: Day (United States of America)
Hours: 40
Contract: Non-Union
Weekend Rotation: None
Job Profile Summary: In this role you will establish collaborative processes that promotes quality and cost-effective care, optimizing the physical and psychosocial health of participants across the continuum of care. You will be responsible for conducting comprehensive assessment, oversight, making decisions that impact health care outcomes. As a Nurse Navigator, you will also independently coordinate complex panel of participants while ensuring an interdisciplinary approach with care team providers that results in an integrated person-centered plan of care. This collaborative care plan is designed to advocate and assist participants in coping with complex health issues and enhance the person’s ability to function and access appropriate services. You will provide clinical consultation as needed to medical providers, pharmacists, non clinical staff, clinical staff and other team members as appropriate.
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Job Requirements

• Bachelor's degree in nursing preferred
• 2 to 5 years of previous care management experience required
• Care Manager Certification preferred
• Licensed Registered Nurse - MN Board of Nursing required or
• Associate's or Vocational degree in nursing required and

Principle Responsibilities

• Maintains contact with participant and relevant circle of support as required/needed to promote best health outcomes.
• Builds trust with participant to encourage full engagement in care planning process and implementation.
• Leads and supports transition and discharge planning for participants moving between levels of care.
• Supports planning across the continuum of care in collaboration with other health care providers, specialty and community providers to facilitate transitions of care.
• Supports planning with community resources and external healthcare agencies to provide broadest available integrated network of support as needs indicate.
• Develops Plan.
  • Develops a person centered care plan that focuses on enhancing strengths to support health and well being.
  • Builds trust with participant to encourage full engagement in care planning process and implementation.
  • Communicates care plan to participant, health care provider and community supports to ensure most effective implementation.
  • Supports planning across the continuum of care in collaboration with other health care providers, specialty and community providers to facilitate transitions of care.
  • Supports planning with community resources and external healthcare agencies to provide broadest available integrated network of support as needs indicate.
  • Maintains high level oversight of the integrated plan to assure goals are met and addressed.
• Monitors Progress Toward Goals.
  • Initiates care plan modifications as necessary through monitoring and evaluation to accommodate changes and encourage optimal health and safety over time.
  • Follows the participant over time, across continuum of care to measure effectiveness of the plan.
  • Adapts plan to meet changing needs.
  • Communicates with participant, family and healthcare providers about changes in plan.
  • Documents all encounters thoroughly in timely manner in designated data system.
• Communicates with participant, family and healthcare providers about changes in plan.
• Communicates issues and decisions relating to committee or project work to other team members, management, and sponsors
• Other duties as assigned.
• Facilitates Implementation of Plan.
  • Maintains contact with participant and relevant circle of support as required/needed to promote best health outcomes.
  • Works with participant, family and providers to resolve identified barriers.
  • Works with participant, family, healthcare providers and community supports to coordinate needed services.
  • Utilizes motivational interviewing skills to facilitate and engage participants towards behavioral changes through exploration and resolving ambivalence.
  • Facilitates communication between participant, family and all members of the health care team.
  • Facilitates referrals for participants as appropriate.
  • Administers health care benefits and coordinates care within the benefit set.
  • Identifies alternate sources of funding if available for services as indicated.
  • Assists participants to navigate health care system and access appropriate services and resources.
  • Addresses complex communication and planning issues as participant receives services across the continuum (in particular for patients with multiple specialists and services).
  • Leads and supports transition and discharge planning for participants moving between levels of care.
• Identifies alternate sources of funding if available for services as indicated.
• Communicates care plan to participant, health care provider and community supports to ensure most effective implementation.
• Administers health care benefits and coordinates care within the benefit set.
• Participates in work groups and committees as appropriate
• Conducts Comprehensive Assessment.
  • Gathers all relevant data and information by communicating with the participant, family, healthcare provider, other members of the healthcare delivery team and community support network including external healthcare providers and agencies.
  • Completes a medication review with attention to eliminating barriers to medication adherence.
  • Uses clinical expertise and established criteria to identify risk factors and determine recommendations to mitigate adverse health outcomes.
  • Evaluates data identifying strengths and barriers including social determinants impacting health and chronic or acute problems or conditions impacting function and quality of life.
• Utilizes motivational interviewing skills to facilitate and engage participants towards behavioral changes through exploration and resolving ambivalence.
• Provides qualified professional oversight as needed to ensure appropriate care plan development.
  • Participates in work groups and committees as appropriate
  • Supervises and delegates to care management support staff tasks that contribute to the plan.
  • Participates in staff and departmental meetings and assists with identification and resolution of problems.
  • Communicates issues and decisions relating to committee or project work to other team members, management, and sponsors
  • Works collaboratively with interdisciplinary care management professionals to design and deliver an integrated care plan.
• Documents all encounters thoroughly in timely manner in designated data system.
• Assists participants to navigate health care system and access appropriate services and resources.
• Develops a person centered care plan that focuses on enhancing strengths to support health and well being.
• Evaluates data identifying strengths and barriers including social determinants impacting health and chronic or acute problems or conditions impacting function and quality of life.
• Facilitates referrals for participants as appropriate.
• Works with participant, family and providers to resolve identified barriers.
• Works with participant, family, healthcare providers and community supports to coordinate needed services.
• Addresses complex communication and planning issues as participant receives services across the continuum (in particular for patients with multiple specialists and services).
• Gathers all relevant data and information by communicating with the participant, family, healthcare provider, other members of the healthcare delivery team and community support network including external healthcare providers and agencies.
• Uses clinical expertise and established criteria to identify risk factors and determine recommendations to mitigate adverse health outcomes.
• Participates in staff and departmental meetings and assists with identification and resolution of problems.
• Facilitates communication between participant, family and all members of the health care team.
• Maintains high level oversight of the integrated plan to assure goals are met and addressed.
• Follows the participant over time, across continuum of care to measure effectiveness of the plan.
• Works collaboratively with interdisciplinary care management professionals to design and deliver an integrated care plan.
• Supervises and delegates to care management support staff tasks that contribute to the plan.
• Initiates care plan modifications as necessary through monitoring and evaluation to accommodate changes and encourage optimal health and safety over time.
• Adapts plan to meet changing needs.
• Completes a medication review with attention to eliminating barriers to medication adherence.

Physical Demands

Sedentary:
Lifting weight Up to 10 lbs. occasionally, negligible weight frequently

Additional :

This position is with our Complex Care for Seniors Program in the SE Metro, including: Inver Grove Heights, Woodbury, Cottage Grove, Hastings etc.

This role is hybrid including work from home and visits to patients in-home with occasional travel to the office required.