RN Transitional Care Navigator (Population Health) - Transitions of Care Program

Hourly Pay Range:

Position Highlights:

• Position: RN Transitional Care Navigator (Population Health) - Transitions of Care Program - Days
• Location: 4901 Searle Parkway, Skokie (Corporate Office)
• Full Time: 40 hours/week
• Hours: Monday - Friday (8:30 am -5:00 pm), 2 days onsite required and 3 days remote optional. Weekend and holiday required per rotation. Remote optional for weekend and holiday coverage.

What you will do:

The RN Transitional Care Navigator (Population Health) for the Transitions of Care Program is responsible for the case management, care coordination management, and utilization management of his/her population of patients across multiple care levels and settings. Serves as a catalyst to promote patients understanding their diagnosis, treatment options, and available resources and ensure that they are connected with the optimal resources across the continuum of care. This role will coordinate and facilitate smooth and safe care transitions 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.

• Guides high-risk 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.
• Establishes and documents an individualized plan of care for assigned patients using evidence-based treatment guidelines considering the patients individual health goals with a focus on wellness, health management, disease prevention and chronic disease management.
• Partners with the healthcare team to ensure clinical decision-making, implementation of recommendations, and discharge planning are timely and appropriate.
• 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.
• Acts as advisor/educator by partnering with social work in 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.
• Facilitates appointments for appropriate consultations and support services within established protocols
• Completes Utilization Management for assigned patients.
• Applies Milliman Care Guidelines (Indicia) criteria to monitor appropriateness of admissions and continued stays and documents findings based on Department standards.
• Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas.

What you will need:

Education:

• Bachelor's degree in healthcare or related field required or minimum of seven (7) years of appropriate experience as noted below.
• Bachelor's degree in Nursing from an NLN accredited school of nursing is preferred.

License: RN required

Certification:

• Clinical certification, such as case management certification, ambulatory care nursing certification is preferred.
• Basic Life Support for Healthcare providers (AHA) or CPR/AED for the Professional Rescuer (American Red Cross) is preferred.

Experience:

• Minimum three (3) years of utilization review, discharge planning, case management or disease management preferred.
• Nursing experience in home services, ambulatory services working with high-risk patients beneficial.
• 2 years of clinical nursing experience preferred.

Skills:

• Adheres to and practices in alignment with contemporary standards of care as established by leading professional organizations, including but not limited to the American Academy of Ambulatory Care Nursing (AAACN), the American Case Management Association (ACMA), and the Case Management Society of America (CMSA).
• Interacts with and contributes to professional development of peers and other health care providers as colleagues.
• Shares knowledge and provides feedback with peers to contribute to an environment supportive of clinical education.
• Knowledge of InterQual or MCG criteria preferred.
• Able to communicate and work collaboratively with a range of stakeholders and team members.
• Knowledge of community resources.
• Experience with Microsoft Office Suite.
• Strong interpersonal and oral communication skills.
• Strong computer and data entry skills.
• Experience with Electronic Medical Record (EMR) platform preferred.
• Proven leadership skills.
• Ability to work independently, setting priorities to coordinate care plan efficiently.

Benefits:

• Premium pay for eligible employees
• Career Pathways to Promote Professional Growth and Development
• Various Medical, Dental, Pet and Vision options
• Tuition Reimbursement
• Free Parking
• Wellness Program Savings Plan
• Health Savings Account Options
• Retirement Options with Company Match
• Paid Time Off and Holiday Pay
• Community Involvement Opportunities

Endeavor Health is a fully integrated healthcare delivery system committed to providing access to quality, vibrant, community-connected care, serving an area of more than 4.2 million residents across six northeast Illinois counties. Our more than 25,000 team members and more than 6,000 physicians aim to deliver transformative patient experiences and expert care close to home across more than 300 ambulatory locations and eight acute care hospitals - Edward (Naperville), Elmhurst, Evanston, Glenbrook (Glenview), Highland Park, Northwest Community (Arlington Heights) Skokie and Swedish (Chicago) - all recognized as Magnet hospitals for nursing excellence. For more information, visit www.endeavorhealth.org.

When you work for Endeavor Health, you will be part of an organization that encourages its employees to achieve career goals and maximize their professional potential.

Please explore our website (www.endeavorhealth.org) to better understand how Endeavor Health delivers on its mission to "help everyone in our communities be their best".

Endeavor Health is committed to working with and providing reasonable accommodation to individuals with disabilities. Please refer to the main career page for more information.

Diversity, equity and inclusion is at the core of who we are; being there for our patients and each other with compassion, respect and empathy. We believe that our strength resides in our differences and in connecting our best to provide community-connected healthcare for all.

EOE: Race/Color/Sex/Sexual Orientation/ Gender Identity/Religion/National Origin/Disability/Vets, VEVRRA Federal Contractor