PURPOSE AND SCOPE:
The promotes quality patient care, ongoing clinical problem solving and customer support for Fresenius Health Partners (FHP) Care Navigation population by providing guidance, support, care coordination, education and other care coordination functions as defined by the pertinent program as assigned while acting as the subject matter expert and resource for patients and caregivers, non-clinical Care Navigation staff, dialysis staff, physicians and other health care professionals. Services are generally provided telephonically but there may be programs where on site visits to clinics, medical offices, hospitals and/or patient homes are required. Programs principally include the Care Navigation Unit but could extend to other Company care management program.
PRINCIPAL DUTIES AND RESPONSIBILITIES: Utilize clinical judgment, independent analysis, critical thinking, time management and detailed knowledge of the Care Navigation Program to facilitate the coordination of care for patients assigned to the Care Navigation unit. Collaborate with clinical and non-clinical staff and other members of the patients health care team to develop an individual plan of care to facilitate an immediate action plan to meet the patients current needs. Communicate and coordinate with patient, appropriate members of patients health care team in developing, executing and reviewing results of care coordination efforts. Collect, review and employ all pertinent medical information available from but not limited to FMC clinical systems, care management notes, hospital discharge information, physician clinical information and patient reported health status. Assess patient condition, in conjunction with clinic staff, such as the discovery of unreported medical or social conditions or changes at home that may lead to adverse outcomes and ensures that these are referred to appropriate sources for attention. Maintain and update related software/tracking logs of patients in the Care Navigation Program to manage and record required information and data. Evaluate program processes and makes recommendations to management that will improve the effectiveness and efficiency of the program. Maintain the integrity of Protected Health Information (PHI). Comply with all departmental required data collection and auditing activities, participates in quality improvement activities and participates in project-based work. Maintain current knowledge of the departmental program software and the Companys clinical information systems. Improve job related capabilities through continuing education, professional seminars and technical workshops
Partners with appropriate teams to provide, coordinate and integrate Treatment Options and Kidney Disease Education programs to reduce the incidence of acute ESRD onset and improve management of co morbid diseases for patients starting RRT. This may include coordination with nephrology practices and assessment, education and intervention with CKD patients. Participates with appropriate staff and teams to facilitate community-focused education initiatives including those for Primary Care Physicians (PCPs), surgeons and nephrology practiceParticipates in meetings to review the CNU and other care management programs Intervenes with patients and caregivers to ensure successful transition into dialysis, including but limited to receiving modality education, permanent access placement and adjusting to the demands of dialysis while maintaining patient identified quality of lifeCollaborates with providers and dialysis clinics to identify and mitigate hospitalization and mortality risk during the first four months of dialysis Assist with various projects as assigned by direct supervisor. Other duties as assigned.
Additional responsibilities may include focus on one or more departments or locations. See applicable addendum for department or location specific functions.
PHYSICAL DEMANDS AND WORKING CONDITIONS: The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION: Bachelors Degree in Nursing, preferred Active, unrestricted state RN license
EXPERIENCE AND REQUIRED SKILLS: 2+ years nursing experience required. Dialysis nursing experience preferred but not required. Must exhibit leadership skills and behaviors and be able to collaborate with both clinical and non-clinical team members to facilitate desired care coordination outcome. Clear and persuasive patient communication skills. Previous successful call center, problem solving and budgeting experience, preferred Excellent verbal, written and meeting presentation skills Successful project management, preferred Excellent analytical and leadership skills Proficient in word processing, spreadsheet, database, presentation and email applications. Organized and detail oriented with a strong bias for follow-up and problem resolution Proven ability to be a team player.
Associated topics: bsn, care unit, coronary, intensive care, maternal, neonatal, psychiatric, registered nurse, staff nurse, tcu