Under general administrative direction, the PALTC Nurse Navigator (NN) shall be an entrepreneurial, enterprising, and inspirational leader with a strong passion for skilled nursing facility (SNF) patient care. The Nurse Navigator collaborates with providers and/or clinical areas to coordinate services and ensure quality of care for patients. Assesses the physical and psychosocial needs of patients and their families throughout their skilled nursing facility journey. This hybrid positon requires skill in physical examination skills, triage, adept use of technology, great collaboration skills, and willingness to travel to local SNF Facilities. Must be able to prioritize workload and respond to facility calls and messages in a timely manner. Demonstrates knowledge of the nursing process as a standard in accordance with licensure, incorporating elements of holistic family-centered care.
KNOWLEDGE/EXPERIENCE: Minimum of 3-5 years’ nursing experience required. One or more year’s acute care experience preferred.
EDUCATION: Graduate of accredited professional school of nursing required. BSN preferred.
LICENSE/CERTIFICATION/REGISTRY: Current Montana License as a Registered Nurse required. Current BLS certification required.
Aptitudes: Demonstrated effective communication skills, both oral and written. Demonstrated effective time management skills, ability to effectively complete multiple tasks accurately and timely. Demonstrated ability to perform research on clinical protocols and to assist physicians to develop and maintain protocols. Demonstrated ability to provide
The Post-Acute Long-Term Care Nurse Navigator will:
Serve as a patient advocate and assist in navigating the process along the continuum with the goal of facilitating effective quality care and timeliness, resulting in improved patient satisfaction and outcomes. Travel to SNF facilities most work days. Coordination with the in facility and/or outpatient care team to provide continuity of care. Build relationships with other patient navigators and improves continuity with similar patients. Work with a multidisciplinary team to develop and implement an up-to-date care plan. Facilitation of outpatient and virtual visits with PALTC providers. Document appropriate correspondence and care in patients’ EMR. Identify and develop relationships with personnel in departments involved in care (i.e., physicians, nurses, social services staff, and both SPH and independent clinic staff). Facilitate/coordinate timely scheduling of appointments, diagnostic testing and procedures to expedite the span of care and promote continuity of care with the multidisciplinary team. Providing support and coaching to residents as they work toward health goals. Coordinating SNF resident care including transitions of care and referrals between SNFs, hospitals, primary care, specialty clinics, and home health as well as other relevant community resources. Facilitating virtual team huddles with SNF providers as they handoff for shift change Managing communication and triage with SNF staff, other providers and care teams regarding resident care (i.e. receive status change updates from SNF, determine the appropriate provider team). Managing referrals to ensure that provider-to-provider communication, scheduling visits, and document exchange occur. Maintaining positive, professional working relationships with local area SNF staff, providing staff education on SNF team standard operations and other care related topics. Assisting the SNF care team to be thoughtful about healthcare service utilization and appropriate use of resources (i.e. mitigating unnecessary ED use) Help initiate and continue interdisciplinary discharge planning, including patient and caregiver planning. Link and assist patients and their families to appropriate national, community, hospital and medical resources. Utilize interventions and strategies appropriate for and respecting patients’ culture, age, gender, socioeconomic, and psycho-social factors. Attend weekly interdisciplinary team meetings. Expertise to identify and implement improvement processes, and the ability to design, direct and implement improvements and programs for patients, with the aim to improve the clinical experience for patients. Maintain personal knowledge base of available resources, both in-house and outside. Identify education/ training opportunities for providers, members, other health care workers and staff in support of health improvement initiatives Maintain and increase knowledge base on post-acute long-term care-related terms, topics, and best practices. Performs other duties as assigned within the PALTC care team and within time frame specified