DaVita Registered Nurse Navigator in Colorado Springs, Colorado
Summary: Registered Nurse Navigator (RNN) is an integral member of a team tasked with developing care management models for risk stratified patients that need interventional care at various levels. RNN is joining an organization that actively participates in capitation contracts and value-based care incentive programs, including CPC+. RNN success will be measured by reported outcomes for various quality metrics and performance against capitation contracts.
RNN works collaboratively with physicians, staff and other healthcare providers to lead patient care coordination across the health care continuum. RNN is responsible for coordinating a wide-range of patient support for post-inpatient, skilled nursing facility and emergency department discharge patients. RNN will also be responsible for developing and executing care plans for complex chronic disease patients that are identified as needing interventional care management at the RNN level.
Essential Duties and Responsibilities include the following, other duties may be assigned:
Coordinating Transition of Care (TOC):
Actively guides patients through post-discharge care, focusing on: inpatient and skilled nursing facility discharges. Contacts patients telephonically after discharge within set guidelines;
Actively guides patients through post-discharge emergency department care. Contacts patients telephonically after discharge within set guidelines;
Coordinates post-discharge patient care with primary care physicians;
Provides education to patients to effectively and proactively manage care and address concerns;
Ensures patients receive ordered ancillary services (ex. home care, durable medical equipment, medication refills, oxygen);
Utilizes multiple resources to identify discharged patients, including but not limited to: automated reporting, payer online portals, provider online portals;
Schedules or facilitates necessary patient appointments with primary care;
Engages with utilization management and discharge planning resources (ex. social workers) to establish seamless transition of care;
Accurately and comprehensively documents in EHR utilizing approved templates and capturing information necessary for quality-measure reporting and evaluation;
Medication reconciliation, as appropriate.
Complex Case Management:
Proactively monitors high risk patients using approved stratification criteria;
Develops comprehensive care management for high risk patients and actively manages on a consistent basis;
Accurately documents care management in patient charts and regularly updates utilizing approved, standardized EHR templates;
Reviews medications and assesses patient adherence.
Population Health Management:
Proactively manages the patient population to minimize avoidable emergency department and hospital admissions;
Takes initiative to identify and remediate gaps in patient care;
Encourages patients to utilize services provided by our clinics for needed and recommended care;
Actively engages in value-based care programs to meet quality measure benchmarks;
Participates in the organization’s transition from volume-based care to value-based care;
Demonstrates successful population health management by: meeting or exceeding quality measures; decreasing ER utilization rates; increasing patient care visits; decreasing admission rates; decreasing costs-per-patient.
Follow established standardized processes and actively engage to improve them;
Participate in patient outreach campaigns, as needed.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
RN required, BSN preferred;
Minimum three years of experience practicing in an acute care environment;
Experience in case management and discharge planning preferred;
Experience in complex care planning and management preferred;
Experience in a capitation environment preferred;
Experience with value-based care models preferred.
Certificates, Licenses, Registrations:
Current RN License in the State of Colorado must be provided at time of hire;
Specialty certification(s) a plus.
To perform this job successfully, RN must have a high level of proficiency and skill working with electronic health records. RN must use the organization’s clinical software programs, including but not limited to: GroupCast, AllScripts EHR, CIIS, Lab and Radiology IT systems. RNN must also be proficient in using the Microsoft Office suite, particularly Excel and Outlook. RNN should also be prepared to use online portals on a daily basis to identify patients and monitor key performance metrics.
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports, correspondence and chart notes neatly, efficiently and effectively. Ability to speak effectively before patients or employees of organization and communicate medical information to non-medically trained people. RNN must also be able to communicate effectively with people of different social, economic, educational and cultural backgrounds.
RNN must possess the ability to apply concepts such as fractions, percentages, ratios and proportions to practical situations. Ability to accurately calculate dosages required.
Ability to define problems, collect data, establish facts, and draw valid conclusions. RNN should also be able to interpret an extensive variety of technical instructions in mathematical or diagram form, including abstract and concrete variables.
Other Skills and Abilities:
Ability to establish and maintain effective working relationships with patients, providers and staff members;
Ability to work independently;
Ability to accept responsibility and take initiative to proceed without direct supervision within scope of practice;
Ability to adapt to a fast-paced environment and multi-task under pressure;
Ability to be flexible and adapt to frequent change.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The employee is frequently required to stand, walk and sit. The employee must occasionally list and/or move up to 50 pounds. Requires manual dexterity to operate standard office equipment.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Work is performed in a non-clinical office environment, under fluorescent lighting. The noise level in the work environment is moderate. Frequent pressure due to multiple calls and inquiries. Temperature may fluctuate.