Role Description
Implements care plans that are specific to each patient's physical, mental, and social needs based on medical and pre-surgical clinical assessments. Ensures smooth transitions and evidence-based disease management for select populations prior to hospitalization and/or a segment of time post-discharge. Works collaboratively as part of a multi-disciplinary team to provide patient and family education and navigation across the continuum of care.
Job Duties
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Identifies patients not meeting clinical goals or important quality metrics and arranges follow-up per protocol, as appropriate.
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Reviews and updates medication list and accurately documents known allergies in the electronic health record (EHR).
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Utilizes registry and other data along with published evidence to assist with the point of care decision making. Supports quality improvements, pilot participation, and other research activities.
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Identifies actual or potential variances in standards of care and system problems that could lead to errors, delays in care, complications, or increased cost.
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Establishes and maintains external relationships with hospitals, rehabilitation facilities, and other post-acute care facilities.
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Provides care navigation services to specialty populations, inclusive of LVHN Specialty Institutes and BPCI-A.
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Collaborates with patient/family in establishing mutual goals based on the patient's needs and problems.
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Identifies issues related to the healthcare system, transportation, financial, and/or psychological barriers and works collaboratively to problem solve, coordinate services, and advocate for patients/families.
Qualifications
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Bachelorβs Degree in Nursing.
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Experience in lieu of Bachelor's degree may be considered.
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5 years Experience working as a registered nurse (RN).
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2 years Previous experience in case management, disease management, home health care, hospital, or physician office setting.
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2 years Prior electronic medical record (EMR) experience.
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Ability to set priorities to coordinate care plan efficiently.
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Utilizes effective strategies for interacting with persons from diverse backgrounds.
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Ability to recognize the role of cultural, social, economic, and behavioral factors in accessibility, availability, acceptability, and delivery of public health services.
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Knowledge of computer applications and analytical tools.
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RN - Licensed Registered Nurse_PA - State of Pennsylvania Upon Hire.
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CACRN - Certified Ambulatory Care RN - State of Pennsylvania Within 3 Years.
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CCCTM - Cert Care Coord-Transition Mgt MSNCB - State of Pennsylvania Within 3 Years.
Preferred Qualifications
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Masterβs Degree Nursing.
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2 years Condition- or population-specific experience (Orthopedics, Cardiac, Pulmonary, GI, Pediatrics).
Physical Demands
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Lift and carry 25 lbs.
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Frequent sitting/standing.
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Frequent keyboard use.
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Patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.
Work Schedule
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Monday-Friday; 8:00a-4:30p with weekend rotation possible.
Address
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1200 S Cedar Crest Blvd
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Primary Location: REMOTE IN PENNSYLVANIA