What is Care Assure? Care Assure is our hospital’s commitment to excellence in follow-up care. Care Assure was created to ensure patients receive appropriate care following hospital visits. Clinically trained Nurse Navigators support patients after discharge from the hospital by answering questions and facilitating follow-up appointments.
By taking a broad view of patient care, Care Assure helps to improve management of disease during the transition from the hospital back into the community.
What Can You Expect From Care Assure? During the weeks following your hospital admission, you should expect to:
Receive calls from a Nurse Navigator who will ensure that you receive appropriate follow-up care
Be supported by a healthcare team who is dedicated to helping you navigate and work through the healthcare system
Interact with Nurse Navigators who will help you understand your discharge plan and work with you to complete follow-up appointments
The Care Assure Nurse Navigator is responsible for the programs and resources that support the navigation of patients through complex healthcare environments for the optimization of care and outcomes. S/he facilitates patient follow-up through coaching, information transfer, and communication in order to improve continuity of care, enhance the medical management of complex disease, and streamline the intervention process. The incumbent guides patients through the health care system by assisting with access issues, developing relationships with service providers, and tracking interventions and outcomes. Serves as a point of contact for referring physicians, patients and caregivers to provide resources and assistance with accessing clinical and supportive care services.
DUTIES INCLUDE BUT ARE NOT LIMITED TO:
The duties and responsibilities listed herein are not intended to be all inclusive but rather to indicate the primary emphasis of the job and establish the parameters for the necessary skill, effort, responsibility and working conditions that make up the job.
Reviews patient case lists generated by technology-enabled data triggers to identify patients that could benefit from intervention.
Communicates with physicians (in the hospital and in the community) about patients' potential for referral / follow-up treatment.
Provides feedback to leadership in regards to target population in order to enhance care coordination and patient satisfaction.
Schedules follow-up appointments and provide information and reminders to patients & physician offices.
Tracks outcomes of referrals and treatments.
Maintains detailed records to measure effectiveness of program and suggest ways to improve throughout the process.
Works with physicians and program leadership on a daily basis
Engages providers and patients in a program that will improve outcomes and the efficiency of medical care.
Performs position specific job functions at an acceptable level.
Reviews clinical progress of patients and coordinates communications to referring, consulting, and primary care physicians.
Plan, organize and provide direct care to the patient, as appropriate, if called upon to do so.
Facilitates the development of a patient specific teaching plan.
Reviews medications /educates patient as needed, Initiates communication regarding dashboard triggers with care team.
Facilitates ongoing performance improvement activities related to the target population and involving all levels of staff.
Educates patient and families regarding planned procedures, medications and treatments.
Evaluate clinical educational need of staff related to target population and facilitates collaboration with clinical care givers.
Makes appropriate referrals as noted by the physician.
Coordinates information among referring, primary care and consulting physicians and ancillary departments.
Participates in creating an environment that implements the mission, vision and values of the organization.
Encourages collegiality and collaboration when integrating pilot services with other departments.
Evaluates and provides input regarding the utilization of resources to meet the needs of the target population.
Plan and delivers weekly status updates.
Reviews pertinent clinical detail including diagnostic imaging studies, lab values and notifies MD as appropriate for abnormal findings.
Completes all other duties as assigned.
Skills: Hospital based computing systems (i.e. Meditech), •Critical thinking, service excellence and good interpersonal communications skills, ability to read/comprehend written instructions, ability to follow verbal instructions, PC Skills/Proficient in Microsoft Office, Excel, Word, ect.
Education: Bachelor’s Degree in Nursing with graduation from an accredited school of nursing required. Will consider candidate with BSN within 6-9 months of hire or currently in school pursing BSN. Masters preferred.
Experience: Minimum 3 - 5 years relevant specialty area experience (i.e. Cardiovascular, Orthopaedic, Neuro., Spine, Oncology) specialty area experience strongly preferred. Knowledge and application of pertinent computer programs and imaging software (I.E. MUSE, PACS, etc.)
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