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Career Opportunities
LHC Group - Nursing Management Careers

Care Transition Navigator Job

Job Number: 2017-13375

Agency: Parrish Home Health

Location: Cocoa, FL

Schedule: Full-Time

Full Job Title: Care Transition Navigator (CTN) - Hospital Position - Titusville, FL

Overview

HOSPITAL POSITION

LHC Group is the preferred post-acute care partner for hospitals, physicians and families nationwide. From home health and hospice care to long-term acute care and community-based services, we deliver high-quality, cost-effective care that empowers patients to manage their health at home. More than 60 leading hospitals and health systems around the country have partnered with LHC Group to deliver patient-centered care in the home. More hospitals, physicians and families choose LHC Group, because our 11,000 employees in 25 states are united by a single, shared purpose: It's all about helping people. Under the supervision of the Assistant Vice President – Ambulatory Services, the Care Transition Navigator is responsible for facilitating a seamless transition for BPCI patients discharging from a facility setting to a post-acute care setting. Included and aligned within this responsibility, is the understanding and implementation of market development initiatives and their role in growth, as we focus on serving more patients and delivering exceptional care. The CTN provides supervision of the Transitional Case Managers and Data Analytics; for the safe transition and coordination of care, and the organization’s ability to meet the needs of the patient. This transition navigator position will oversee and assist with the assessment of each patient to determine their level of health literacy and be adept at ensuring the patients and families are included in care planning. Following identification of needs, the CTN will oversee the best practice intervention and education to improve patient outcomes and promote patient self-management. The CTN will implement re-hospitalization reduction initiatives for patients with Acute Care Hospitalization risk and continually communicate and maintain collaborative relationships with the hospital, surgeons, and post-acute providers during all phases of transition from the facility into a post-acute care setting.

Additional Details

Our company, a part of LHC Group, is currently seeking clinicians/professionals that want to join our team to help improve the well being of our patients and their families.

89% of our 380 locations have a 4.5 star rating or greater, and we are helping drive better outcomes for our patients nationwide.

If you're seeking a unique opportunity to take your career to the next level, it just arrived!

  • Do you want to be rewarded for your hard work?
  • Do you desire to make a difference providing quality care?
  • Do you want to be part of a family and not just an employee?
  • Flexible schedule for field clinicians
  • Competitive pay

LHC Group is the preferred post-acute care partner for hospitals, physicians and families nationwide. From home health and hospice care to long-term acute care and community-based services, we deliver high-quality, cost-effective care that empowers patients to manage their health at home.

Qualifications

Bachelor’s Degree required with Master’s preferred. RN strongly preferred or equivalent combination of education and experience.

Minimum: 2-3 years general health care business administration or clinical experience in a hospital or post-acute setting.

FUNCTIONS

  • Develops and maintains collaborative relationships with hospital, surgeons, and post-acute providers, and facilitates an evidence-based, multi-disciplinary approach to support patients via navigation of the healthcare continuum.
    • Following Right of Choice; meets with patients/families and coordinates transitions of care by reviewing the physician order for appropriateness and level of care identification, and assessing the patient’s clinical needs. Communicates with patient and family members as they move from one level of care to another.
  • Assesses literacy level and progress on self-management goals. Identifies care needs and refers to appropriate interdisciplinary care team member and/or community resources. Works closely with surgeon or primary care provider to incorporate the assessment and referrals into plan of care.
  • Coordinates efforts to improve patient outcomes and reduce readmissions by explaining physician orders, ensuring physician office visits, monitoring medication reconciliation, and following up on outstanding tests and procedures in the post-acute-care environment. Assists in obtaining all necessary prescriptions prior to patient’s discharge from hospital when applicable; and ensures coordination of other ancillary services for the patient (DME/Infusion) as needed.
  • Provides education to patient and family members on diagnosis, medication, medication reconciliation, nutrition and fall risk reduction. Ensures patient and family members have the necessary contact information and are educated on who and when to call for assistance. Ensures the introduction of patient/family to post-acute care settings.
  • Works with involved physicians on developing and implementing protocols for patients who are discharged to an IRF, SNF, Home Health agency, or outpatient therapy; and ensures availability of physicians to follow the plan of care. Develops a communication system and weekly meetings with SNF and IRF to ensure that patient is adhering to designed protocol and progressing as expected. Discusses and approves any outliers from established protocol.
  • Regularly monitors the post-acute facilities’ star ratings to ensure that they meet the standards and expectations of Parrish Medical Center.
  • Takes an active role in facilitating communication of patient needs to the physician in an effort to avoid unnecessary delays in care/functional improvement/ readmissions.
  • Serves as a liaison between Parrish Healthcare and all involved healthcare providers of newly referred patients, as well as existing patients transferred to the hospital from the post-acute care settings. At the same time, the navigator ensures communication with the patients and families to make sure all needs are met.
  • Ensures communication to Discharge Planning/Transitional Case Managers for any active patients that transfer from post-acute care services into a facility, and ensures the resumption of coordination of care with patient and Discharge Planning prior to discharge.
  • Monitors clinical progress for the first ninety days after transition to the post-acute environment. Communicates delays in care, functional status and/or changes in clinical status to the surgeon or primary care provider (PCP) and coordinates required follow-up and monitoring. Monitors BPCI program performance against established goals and reports variances to Assistant Vice President of Ambulatory Services weekly.
  • Monitors clinical, quality, patient satisfaction, and other key regulatory metrics. Provides support in data collection and other performance management efforts. Develops a physician report that monitors the key metrics of each BPCI patient and the participating physicians. Manages and reports on the key metrics that are identified as the key measures of success for each BPCI initiative. Serves on organizational committees, if requested, and works with hospital focus groups to assist in systems integration and process improvements, which result in improved patient outcomes and transitions of care. Communicates with team and continually analyzes best practices and opportunities to provide care to and reach any underserved population within our service areas.
  • Participates in organizational meetings, as scheduled, with staff, clinical and administrative leadership, Medical Director, and Medical Advisory Board. Attends in-services when required, and facilitates educational in-services to effectively communicate the features, benefits, and programs to educate staff as to what services are available. Develops and coordinates a “daily huddle” meeting with physician and acute therapist representative to discuss the discharge plan.
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