Under the direction of department leadership, the Hospitalist Nurse Navigator provides services consisting of comprehensive care coordination and continuing care services. The Nurse Navigator is accountable for a designated patient caseload/population and plans effectively in order to meet patient needs. The Hospitalist Nurse Navigator is a support to providers and collaborates closely with the rest of the multi-disciplinary team. The Hospitalist Nurse Navigator strives to enhance the quality of clinical outcomes and patient satisfaction while managing the cost of care.

Essential Job Functions
 Assessment
• Conducts initial and ongoing assessments and chart reviews of each assigned patient to identify potential and or actual barriers and care needs.
• Acts as a liaison with referral sources, post-acute teams and ambulatory settings by coordinating orders, supplies, appointments and medical records.
• Coordinates care and transitions while the patient is in the acute setting with both providers and care teams.
• Engages and collaborates with patients, support systems and the multidisciplinary/healthcare team to establish a plan of care that addresses the mutually identified needs of the patient.
• Assists and collaborates with the care management teams in reducing barriers and improving communication with the hospitalists.
• Assists and collaborates with nursing/unit care teams in reducing barriers and improving communication with the hospitalists.
• Participates in patient throughput workflows and collaborates to break down barriers to assist in the transition to ambulatory care.
• Anticipates post-acute needs of patients to improve transitions of care. (testing results follow-up and communication, improving pre-discharge scheduling of ambulatory visits, collaborating with the multi-disciplinary teams to assist in transitions of care.

Interventions and Care Coordination

• Demonstrates the ability to interpret clinical information and understand health care treatment and systems.
• Supports patients to ensure they can function to the best of their ability and maintain optimal health related to their medical condition(s). Identifies and addresses gaps in knowledge/understanding/education related to disease management.
• Participates in the patient’s plan of care by interacting/collaborating with patients, support systems, healthcare professionals and community and state agencies. Serves as a liaison between provider, hospital, clinic and community agencies to facilitate the exchange of clinical and referral information.
• Identifies high-risk patients through risk stratification tools and ongoing assessments including ED utilization and hospitalizations to address the medical/psychosocial/financial needs of patients and their support systems in both hospital and ambulatory settings.
• Reinforces goals of care and treatment plans with patients and support systems in order to enhance patient and support system engagement.
• Coordinates care conferences to support effective communication as needed.
• Helps navigate the patient throughout the continuum of care.
• Effectively collaborates and coordinates care with the RN Care Manager, Social Services Care Manager, Utilization Review RN, Physician Advisor and Care Management Assistant.
• Maintains current knowledge of community resources and ancillary clinical services to meet the needs of hospital, clinic and regional customers.
• Provides information about available resources to patients and their support systems.
• Acts as a clinical resource to the care team.
• Understands consultative disciplines and their role in patient care.
• Maintains respectful and professional communication skills.
• Insurance and Utilization Management
• Maintains working knowledge of CMS requirements and readmission penalties.
• Maintains working knowledge of insurance/payer benefits.

Insurance and Utilization Management
• Maintains working knowledge of CMS requirements and readmission penalties.
• Maintains working knowledge of insurance/payer benefits.

Evaluation
• Monitors the need for revisions in the plan of care and makes recommendations to the multidisciplinary/healthcare team when indicated. Modifies the plan of care/goals to reflect changes in patient or their support system status and needs.
• Monitors, evaluates and documents patient progress related to plan of care.

 Documentation
• Documents accurately and in a timely manner in the Electronic Medical Record per program guidelines.
• Utilizes standards of professional practice in all documentation and communication consistent with organization/department policy as well as the Board of Nursing and ethical guidelines established and universally supported by the nursing profession.
• Documentation and patient information shall be secured and maintained in accordance with Billings Clinic policy, HIPPA, state and federal guidelines.

Safety/Quality Assurance/Risk Management
• Identifies service gaps and participates in hospital and department programs to address and improve quality of care.
• Advocates for marginalized or vulnerable populations by identifying cases of abuse and neglect and appropriately involving risk management and regulatory agencies.

Professional Accountabilities
• Participates in continuing education, department planning, work teams and process improvement activities.
• Maintains current Licensure.
• Adheres to department and organizational policies addressing confidentiality, infection control, patient rights, medical ethics, advance directives, disaster protocols and safety.
• Demonstrates the ability to be flexible, open minded and adaptable to change.
• Maintains competency in organizational and departmental policies/processes relevant to job performance.
• Utilizes standards of professional practice in all communication with patients, support systems and colleagues consistent with the Board of Nursing and ethical guidelines established and universally supported by the nursing profession.
• Performs all other duties as assigned or as needed to meet the needs of the department/organization.
• Collaborates with post-acute services, Ambulatory Care Managers and PCP’s to ensure successful transition back to the home environment. Makes appropriate Ambulatory Care Management referrals. Anticipates those patients who may require more support after hospital discharge and communicates these concerns.
• Utilizes length of hospital stay, past utilization of resources and risk stratification to identify patients at high risk for readmission.
• Interfaces effectively with the Utilization Review department to stay current on patient’s eligibility for admission, continuing stay, or readiness for discharge.
• Communicates with medical staff, coordination team and nursing staff regarding appropriateness of admission, need for continued stay and discharge plans.
• Identifies and records episodes of avoidable days.
• Evaluates the appropriateness of care delivery in the inpatient setting and communicates any discrepancies with the medical team.

Minimum Qualifications
Education
•Bachelor of Science in Nursing (BSN) or Bachelor of Arts in Nursing (BAN) preferred

Experience
•Five (5) years of professional nursing experience

Certifications and Licenses
•Current Registered Nurse license in the state of Montana

•Certification in a nursing specialty or leadership preferred