RN Transitional Care Navigator - FT - Days - Transitional Care Management

Responsible for identifying and assessing high risk patients upon admission, providing inpatient education and transitional care navigation service designed to enhance quality of care and reduction of 30-day readmissions. POSITION EDUCATION/ QUALIFICATIONS­ : Texas Registered Nurse (R. N.) license required ACLS; BLS Certification required Minimum of three ( 3 ) years of hospital experience in a progressively responsible position requiring contact with various departments.

Ability to communicate clearly and concisely with all levels of nursing, administration, and physicians Demonstrated leadership experience Ability to read, write and speak English required Ability to speak Spanish preferred JOB KNOWLEDGE/EXPERIENCE­ : Representative challenges of this position include determining the validity of collected data, appropriate statistical means to analyze the data, and which charts and reports best represent and display the quantitative data.

High degree of competency/experience in general. Requires good communication and organizational skills. Must Requires reasoning ability and good independent judgment.

Requires working with frequent interruptions. Must project a professional image. Working knowledge of personal computer and software applications used in job.

POSITION RESPONSIBILITES: Assists with appropriate data collection and data analysis based on interaction with patient prior to discharge and transition to community. Reviews and interprets patient care information, discharge summaries, operation reports, and other data sources used to assess transitional care issues and engages with “at risk” patients to include after patient is discharged. Assess fit of proposed interventions with eligible patients and reinforces understanding of signs and symptoms, medication, nutrition, etc.

Discuss interventions with patient/family and identifies barriers to compliance with care plan. Obtain consent and enroll patient or opt out of proposed interventions. Creates reporting documents for departments to use for tracking quality activities, trends and patterns, and identifying opportunities for improvement.

Collect root cause information regarding readmissions and provides education on data analysis and utilization of information. Attends and may facilitate department meetings, providing input regarding problem identification and resolution, transitional care improvement, and other patient care activities. As requested, prepares reports for, and recommends research topics to appropriate committees and/or departments.

Develops record keeping and reporting functions and maintains appropriate files. Completes and maintains records for appropriate follow-up care. Coordinates access to clinical and community based resources as appropriate.

Maintains and distributes corrective action reminder report to responsible persons. Able to travel and make home visits as needed. All other duties as assigned.

Other information: CUSTOMER SERVICE: Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C. A.

R. E. S program which outlines the Customer Service Principals including: Commitment, Accountability, Respect, Excellence and Service.