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Navigates patient and family members through the intake, diagnosis, treatment, and follow-up of the patient throughout the continuum of care ensuring smooth transitions between care settings. Collaborates with a multi-disciplinary team to support patients and families in addressing the following dimensions of care: education, psychosocial needs, advocacy, and continuity of care.
Job Responsibility:
Navigates patient and family members through the intake, diagnosis, treatment, and follow-up of the patient throughout the continuum of care ensuring smooth transitions between care settings
Collaborates with a multi-disciplinary team to support patients and families in addressing the following dimensions of care: education, psychosocial needs, advocacy, and continuity of care
Completes a nursing assessment to identify the patient's individualized needs and collaborates with multidisciplinary teams across ambulatory and acute sites and departments to develop an interdisciplinary plan of care
Supports the patient and family by providing education, addressing psychosocial needs, advocating, providing continuity of care, and mitigating barriers to care
Provides expert clinical advice to the multidisciplinary team in designing collaborative teaching plans/programs and in planning/providing patient/family education and discharge planning including wellness and health maintenance within designated specialty
Coordinates timely, seamless, evidenced based care across the care continuum resulting in optimal patient outcomes
Evaluates, selects, or designs patient education materials on specific disease site programs
Provides individual and group-based education and outreach to patients (new, existing, and potential), internal care teams, and members of the community
Manages patient care access points for new, potential, and existing patients including engaging in daily rounding, intake of patient calls, and self-referral tools
Intakes and connects both provider-referral and self-referral patients to appropriate care teams
Designs and facilitates support group sessions for medical and surgical patient populations
Facilitates appropriate and prompt access to primary care providers, physician specialists, and other services as needed
Monitors medical and surgical patient registries to identify patients overdue for visits, labs, or referrals
arranges follow-up services as appropriate and updates health information records
Supports service line growth initiatives to meet or exceed budgeted volumes
Monitors physician referral patterns and partners with leadership to engage in community outreach
Assist leadership in developing program vision, goals, and objectives
Assists in the development, implementation, and maintenance of quality programs that include best practice patient care outcomes, including quality of life and enhanced patient loyalty
Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served
Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures
Requirements:
Bachelor's Degree in Nursing
Typically requires 5 years of experience in clinical nursing that includes experience in nursing assessment, care plan development, and patient education across acute and ambulatory care settings
Experience in Acute and/or Ambulatory weight management care settings preferred
Working knowledge of the components of quality and patient care needs specifically related to the area in which care will be performed
Maintains clinical expertise to effectively manage physical, emotional, psychosocial and spiritual needs of patients throughout the care continuum
Excellent analytical and interpersonal communication skills necessary to negotiate with families, patients, physicians and third party payers
Demonstrated ability to work well with physicians and other professionals in a direct and positive manner
Registered Nurse license issued by the state in which the team member practices
Basic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association (AHA) needs to be obtained within 6 months unless department leader has determined it is not required
Clear oral communications and hearing acuity required for receiving instructions and converse on standard telephone
Functional speech and hearing to allow for effective communication of instructions and conversation over the telephone
Nice to have:
Experience in Acute and/or Ambulatory weight management care settings preferred
What we offer:
Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions
Opportunity for annual increases based on performance