Department: All Clinical Sites; Travel Involved
Work Week: Monday -- Friday with Rotating On-Call Work
Job Summary:
The nurse navigator will provide telephonic and in person case management/care coordination to Medicare members enrolled in the Bundled Payment Program as well as commercial payer patients ---------- strives to work collaboratively with our patients, providers and care givers to ensure a positive outcome, throughout the continuum of care.
Job Role and Responsibilities:
- Responsible for managing a group of Medicare and other payer orthopedic populations throughout a ninety-day episode of care as part of the Bundled Payment Care Initiative with the goal of optimizing resource utilization and achieving exceptional patient outcomes.
- Gathers clinical information from the EMR and telephonic and live health assessments to determine risk stratification. (This includes a comprehensive assessment of physical, emotional, psychosocial, and environmental needs of the patient)
- Documents clinical assessments and care plans in Pinpoint case management system and Allscripts EMR system.
- Educate the patient and caregiver of the process and expectations of the health care delivery system throughout the periods within the episode of care: Preoperative, Acute Care, Home Health Care, Short Term Rehab, and Outpatient Physical Therapy.
- Manages all pre-procedure/visit patient communication and education to ensure that the patient is prepared for the procedure, resulting in improved patient satisfaction and outcomes.
- Develops and implements care plans throughout each transition of care to ensure the patient’s well-being and optimal functioning.
- Collaborate with multidisciplinary team members in the practice, acute, post-acute and outpatient settings to identify patient needs such as home health care, DME, physical therapy and community services.
- Follows up on patients at pre-determined intervals and as needed based on patient status, via telephonic and on-site interactions.
- Completes and submits all required documentation within established guidelines.
- Evaluates and revises a plan of care on an ongoing basis as determined by patient's health status and communicate changes to all other disciplines involved in the patient's care.
- Communicates with providers and multi-disciplinary care team members to facilitate transition of services throughout the continuum of care.
- Identifies gaps or barriers in treatment plans to ensure that discharged patients receive appropriate resources and services.
- Understands the Bundled Payment Program design, implementation, management, monitoring and reporting requirements.
Education and Experience:
- Current unrestricted RN license
- Minimum of 2-3 years nursing experience in an acute care or hospital setting or case management experience required.
- Preferred candidates experience with discharge planning and outpatient care coordination.
- Orthopedic experience preferred.
- Excellent interpersonal and customer service skill
- Strong problem solving skills with a flexible and creative approach.
- Ability to work independently.
- Excellent oral and written communication skills: able to communicate professionally and effectively with all member of the healthcare team as well as in simple, concise and soothing language to patients and their families.
- Uses appropriate telephone etiquette when performing telephonic duties
Strong computer skills, Microsoft word and excel.
Pay Range: $37.50 to $46.00
Benefits of Working at SOS
- Work life balance, including weekends, evenings, and holidays off
- Part of a team that helps restore function in our community
- RNs, LPNs, and Mas work together in a team atmosphere
- Opportunities for overtime working SOS PLUS Walk-In Care
- On site and free parking, steps away from the office you work
- Educational assistance with reimbursements for expenses associated with continuing education courses
Additional Benefits Working at SOS
Establish Your Future at SOS!SOS is looking for hardworking, caring individuals who want to make a difference. SOS is seeking to fill positions for RNs in our offices around Central New York. These positions include opportunities working in an orthopedic medical office and at our surgery center.
Join a Team that Values You
Listen to what SOS surgeons say about the nurses at SOS
Hear directly from our nurses at SOS
Shannon S., RN - Operating Room at SOS' Specialists' One-Day Surgery
Shannon M., RN - Medical Office at SOS