Visiting Physicians Association Job - 30601824 | CareerArc
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Company: Visiting Physicians Association
Location: Mentor, OH
Career Level: Mid-Senior Level
Industries: Healthcare, Pharmaceutical, Biotech


Nurse Navigator

U.S. Medical Management (USMM) is an affiliate of a leading Fortune 100 company. A national organization built on a continuum of care with premier healthcare providers, clinicians and patient focused individuals working together. Our Mission Through Compassionate Patient-Centered Care in the Home; We will Provide Exceptional Outcomes across our Continuum of Services Visiting Physicians Association, Pinnacle Senior Care, Grace Hospice, Comfort Hospice, Home DME & our In Home Health Assessments (IHA).

Our Values of Integrity, Respect, Teamwork & Excellence are leading us to a better tomorrow for patient care. Our Purposes Centered on We are Unified in our Work through our Continuum of Services We can Find Comfort that We are Making a Difference for our Patients & We make a Broader Positive Impact on Society, allows USMM to be poised for a phenomenal future.

We are seeking candidates who desire the experience of delivering quality & compassionate healthcare within proven care models with patients at the forefront of everything we do.

Position Description

A Nurse Navigator works closely with the Visiting Physician, other health providers and specialty services to maximize the health status of the homebound patient. This position requires contact with the high risk patients and their care givers to perform barrier assessments, offer solutions to improve patient care, serve as an advocate to identify life goals and provide input in the treatment planning process. A Nurse Navigator will also ensure the coordination and communication of a patients treatment plan and general status to all providers and care givers during the continuum of care. This position requires advanced nursing knowledge and expertise to identify a patient need in the home and the ability to direct and implement care coordination plans for hospice or home care when medically appropriate in the home setting.

Essential Duties and Responsibilities

  • Provides on-site clinical coordination
  • Coordinates the transition of care for patients throughout the continuum to ensure patient needs are met accordingly via case conferencing with providers and continuum partners
  • Collaborates with all continuum partners (providers, VPA/Grace/PSC staff, patients/families, community agencies, clinical liaisons)
  • Serves as an educational resource regarding hospice and home care for providers, patients, and caregivers
  • Perform a needs assessment of very high-risk patients (with their input) to maximize or improve current health status and independence
  • Confirm that appropriate home care, hospice, and other ancillary services are in place and are being delivered as directed by the care team
  • When necessary or as directed, travel to patient locations such as a hospital, skilled nursing facility, an in the home to assess patient needs and status
  • Review patients charts to identify gaps in care, potential hospice or home health referrals, and coordinate services with the care team to manage these issues
  • Educate the patient and the caregiver on the importance of care in the continuum; this will enable providers to communicate with each other, identifying gaps in care, reduce hospital readmission, improved outcomes and patient satisfaction
  • Facilitate communication of patient status and plan of care during transitional experiences such as home to hospital, hospital to post-acute care facility, and back home
  • Works closely with all providers [Physicians, Nurse Practitioners (NP), Physician Assistants-(PA)] regarding:
    • Criteria for hospice and home care referrals
    • Community resources inthe specific geographical service area
    • Case conferencing to coordinate care, improve documentation and communication
    • Patient education materials
  • Facilitates/leads continuum meetings to facilitate appropriate participants discussion regarding utilization of continuum resources to meet patient and family needs
  • Assists with documentation to support the eligibility of patient under the care of hospice or home care (which may include chart audit worksheet, Labs, diagnostics, History and Physical, Fast Scale, Mortality Risk Scale, etc.*)
  • Utilize clinical tools such as protocols, physician orders, and care coordination models to maximize patient care.
  • Participates in developing and enhancing tools and educational programs that promote patient services:
    • Provides or arranges for in-services for continuum staff
    • Attends all required meetings (monthly staff, etc.) and in-services
    • Provides periodic ride-along with physician Providers (Physicians, NP/PAs)
    • Identifies any potential opportunities for improvements within the program/continuum or any needed program development
    • Provides/Coordinates educational opportunities for continuum staff on an as needed bases to include participation in new hire orientations
  • Complete and submit reports and data on a daily, weekly, and monthly basis to track volume and productivity
  • Manages time effectively to ensure all duties and documentation requirements are completed in a timely manner
  • Maintains communication with the Director of Nurse Navigators regarding compliance, job performance and significant patient care issues as they arise

REQUIRED Knowledge, Skills and Experience

  • Active R.N. License
  • 1-2 years of hospice experience
  • Ability to perform extensive telephone assessment
  • Knowledge of Medicare regulations and home care and hospice standards
  • Experience with small group presentations and teaching/training
  • Understanding of adult learning principles
  • Exhibits excellent interpersonal skills
  • Working knowledge of computer programs (email, Word, Excel, PowerPoint, etc.)
  • Must be very structured, organized, very detailed and able to meet deadlines

Preferred Knowledge, Skills and Experience

  • Nurse Practitioner License
  • Home Health and care management experience
  • Leadership and/or marketing experience

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