UnityPoint Health Transition Navigator (RN) in Rock Island, Illinois
Transition Navigator (RN), 1.0 FTE Days with some weekends/call, exempt, Fulltime Benefit Eligible. Responsible for the coordination of care and services for the patient through collaboration with the interdisciplinary team to achieve department and hospital goals related to care coordination, reduction of readmissions and efficient acute care stays.. The Transitions Navigator ensures safe and effective transfers across the continuum of care by providing guidance to patient/family for efficient care transition and to improve self-management of their disease process. Monitors plan of care to address physical and psychosocial needs and provide problem solving assistance. The Transition Navigator coordinates services, discharge planning, referrals to appropriate community agencies and assists with Advance Directives when appropriate. Promotes communication and collaboration among members of the interdisciplinary team, patient/ significant others to ensure that specific patient centered outcomes are achieved with variances minimized and evaluated.
I. TECHNICAL/ADMINISTRATIVE/CLINICAL: Demonstrates competence in the skills necessary to carry out assigned duties as identified below. A. Principle Duties and Responsibilities: 1. Collaborate with providers and clinical staff to identify appropriate patients for services using high risk screening tools. 2. Provide information and guidance to patient/family for an effective transition. 3. Evaluates each patient’s condition, diagnoses, medications and support system to develop an individualized care plan that is communicated to providers. 4. Collaborates with patient, family and other members of the healthcare team to address patient needs related to care coordination. 5. Ensures discharge planning process is implemented in a timely manner, communicated to members of the interdisciplinary team and documented in the medical record. 6. Identifies need for POA or Advance Directives and provides assistance or facilitates referral to SW Care Coordinator. 7. Displays thorough and accurate documentation of assessments, interventions and plans related to care coordination and discharge planning 8. Adheres to requirements of CMS, The Joint Commission and other payors related to coordination of care, discharge planning, patient interventions and documentation.
II.DEMONSTRATION OF VALUES: Consistently demonstrates Trinity’s values in the performance of job duties and responsibilities. A. Demonstrates Excellence – A standard of the highest quality in the service we deliver to meet the various needs of our customers. B. Demonstrates Flexibility – An openness to the change which accompanies the exploration of new ways of delivering service. C. Demonstrates Integrity – The assurance that all our dealings with patients and their families, physicians, employees, suppliers, and the community members and others with whom we do business, will be filled with respect, fairness and honesty. D. Demonstrates Responsiveness – A commitment to work with others to identify the needs of our customers and to strive to meet these needs. E. Demonstrates Service – A pledge to offer appropriate services to all persons, regardless of socioeconomic status, race or religion. F. Demonstrates Teamwork – A cooperative effort, involving employees, physicians, patients, and community members, working together to provide quality, compassionate, cost-effective health care.
III. PRINCIPLES OF HOSPITALITY: Consistently demonstrates Trinity’s Principles of Hospitality when interacting with patients, families, physicians, co-workers, visitors, and others. A. Is friendly. B. Responds quickly. C. Takes ownership. D. Is a valued information resource. E. Shows respect for others. F. Provides value-added service. G. Projects a professional image IV. Uphold Trinity’s ACES Standards of Behavior & principles of FOCUS. V. CORPORATE INTEGRITY PLAN: Consistently demonstrates support of Trinity’s Corporate Integrity Plan in the performance of job duties and responsibilities. A. Develops and maintains knowledge of current rules, regulations, policies, and statutes that affect his/her job. B. Monitors his/her work area to ensure corporate integrity issues are identified and addressed. C. Reports Corporate Integrity Plan compliance issues in an appropriate and timely manner. D. Supports Trinity’s Corporate Integrity Plan.
VI. PERSONAL/PROFESSIONAL COMMITMENT: Consistently demonstrates appropriate commitment to professional development. A. Completes all mandatory in-services and competency requirements. B. Assumes responsibility for professional growth and development. Pursues opportunities for professional enrichment. C. Utilizes supplies and resources of the organization in a cost-effective manner. D. Maintains commitment to working scheduled hours. Knows and follows the Safe Operating Procedures (SOP’s) for the department/unit. Takes appropriate measures to prevent unsafe actions or conditions from resulting in harm to self or others. Reports accidents/injuries in a thorough and timely manner. Reports for duty in the proper mental, physical, and emotional condition.
EDUCATION, TRAINING & EXPERIENCE: Registered Nurse with three to five years clinical experience in an acute care, intermediate care or home care setting preferred. Previous case management and/or care coordination experience preferred. RN required. BSN or equivalent advanced degree preferred.
KNOWLEDGE, ABILITIES & SKILLS: Knowledge of Medicare Conditions of Participation and Joint Commission Standards preferred. Knowledge of community resources and agencies preferred Excellent verbal and written communication skills, including the ability to communicate with physicians, hospital staff, patients, families and community agencies required. Ability to negotiate and establish effective working relationships with members of the interdisciplinary health care team, patients and families required. Ability to identify and act upon psychosocial needs and work independently in outcome oriented environment required. Above average skills with computer and software programs required.
LICENSES, REGISTRATIONS AND CERTIFICATIONS: RN license in Iowa and Illinois required. (License in second state must be obtained within 30 days of hire.) CPR certification required within 6 weeks of employment.
Requisition ID: 2018-45211
Street: 2701 17th St
Name: 6020 UnityPoint Health QC Trinity
Name: Case Management
FLSA Status: Exempt
Scheduled Hours/Shift: Days 8-1630 - some weekends and on call
External Company URL: http://www.unitypoint.org
Work Remotely within the US: No