Transitional nurse navigator - chf/copd | Bel Air, MD

Detailed Information

  • Location: Bel Air, MD

needs; developing a Transitional Plan that addresses those needs; identifying and leveraging appropriate resources to implement the plan; and regularly evaluate patient progress according to the plan. Finally, the TNN communicates patient care updates and other relevant information to all stakeholders in a timely and reliable manner.

Identifies high risk patients through use of prospective risk stratification tool (e. g. START, LACE)Completes comprehensive Psycho-social backssments, consultation, treatment, and discharge recommendations. Provides complex care planning to high-risk patients in the community, meeting with them face to face before, during, or after PCP visits, according

to established program protocols and policies. Accepts responsibility for patients' Transitions of Care, coordinating provisions for discharge from facilities including follow-up appointments, home health, community services, transportation, etc.

in order to maintain continuity of care. Coordinates and facilitates communications between all patient settings, including acute care, ambulatory, short stay, skilled nursing, palliative care and hospice. Promotes patient self-management, educating patients on disease, medication, access to care, self-care support, to improve clinical outcomes and increase patient self-efficacy. Conduct follow-up telephonic care calls to patients and families,

according to program protocols and policies. Consults regularly with the inpatient provider, PCP, Director and Supervisor, and other team members to ensure that the transition plan remains relevant, appropriate, and responsive to changing patient status and/or goals.

Reviews /triages CM and other provider referrals to determine program and service needs of patients referred Maintains effective relationships with patients and families, inpatient providers, PCPs and office staff, other providers, community-based agencies, and payers, facilitating interdisciplinary team meetings. Collaborates and implements plans in accordance with established policies, prioritizing patient care goals and needs.

Meeting with patients, patients' family and caregivers as needed to discuss transitional care and treatment plan. Works proactively with clients, caregivers, attending and primary care physician to create Advanced Care Plan documents including Advanced Directives and MOLST. Maintains accurate and complete records, initiates and oversees data entry into IT systems, documents all care rendered, pertinent patient information, all communications, and all care management decisions in appropriate database/electronic record. Uses, protects, and discloses University of Md Upper Chesapeake Health patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards Performs additional duties as assigned.

Company Description University of Maryland Upper Chesapeake Health (UM UCH) offers the residents of northeastern Maryland an unparalleled combination of clinical expertise, leading-edge technology, and an exceptional patient experience. A community-based, integrated, non-profit health system, our vision is to become the preferred, integrated health system creating the healthiest community in Maryland.

We are dedicated to maintaining and improving the health of the people in our community through an integrated health delivery system that provides high quality care to all. Our commitment to service excellence is evident through a broad range of health care services, technologies and facilities. We work collaboratively with our community and other health organizations to serve as a resource for health promotion and education. Today, UM UCH is the leading health care system and second largest private employer in Harford County. Our 3,500 team members and over 650 medical staff physicians serve residents of Harford County, eastern Baltimore County, and western Cecil County.

University of Maryland Upper Chesapeake Health owns and operates: University of Maryland Harford Memorial Hospital (UM HMH), Havre de Grace, MD University of Maryland Upper Chesapeake Medical Center (UM UCMC), Bel Air, MD The Upper Chesapeake Health Foundation, Bel Air, MD The Patricia D. and M. Scot Kaufman Cancer Center, Bel Air, MD The Senator Bob Hooper House, Forest Hill, MD Qualifications Education & Training: Minimum of three years of nursing experience required. Current Maryland RN license required.

BSN preferred. Work Orientation & Experience: Three (3) years nursing care experience required. Case Management experience required. Experience with quality based reimbursement models, utilization management, or outpatient medical practice preferred. BLS required. Skills & Abilities: Demonstrate skill in a) effective critical thinking skills both written and oral; b) facilitating patient access to community resources; and c) Possess working knowledge of discharge planning concepts including guidelines associated with Medicare, Medicaid, acute, post-acute, and skilled home care; d) Ability to communicate and collaborate effectively with both internal and external customers; e) backss, adapt, and calmly respond to changing and/or crisis environment; f) make independent decisions consistent with current policies, procedures, and ethical standards; g) prioritize work assignments and manage time effectively to complete duties; and h) assist in data analysis and computer literate in word processing, Excel, and data management skills.

Additional Information All your information will be kept confidential according to EEO guidelines. For more details: jobs-search. org/advertising_bel-air-c434107/transitional-nurse-navigator-chfcopd-bel-air_i1956424562

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