Nurse Navigator – Community Care Center Position Available In Bristol, Rhode Island

Job Description:

Location Detail:

132 Jefferson St Hartford (10483)

Shift Detail:

Monday to Friday, 8am to 430pm Work where every moment matters.

Every day, more than 40,000 Hartford HealthCare colleagues to workwith one thing in common: Pride in what we do, knowing every momentmatters here. We invite you to become part of Connecticut’s mostcomprehensive healthcare network. Hartford Hospital is one of thelargest and most respected teaching hospitals New England. We are aLevel 1 Trauma Center that provides cutting edge treatment to itspatients. This is made possible by being home to the largestrobotic surgery center in the Northeast and the Center forEducation, Simulation and Innovation (CESI), one of themost-advanced medical simulation training centers in the world.

When hospitals cannot provide the advanced care, expertise and newtreatment options their patients require, they turn to us. TheCommunity Care Clinic (CCC) is located at 132 Jefferson St on thethird floor of the Hartford Hospital Community Health building ofHartford Hospital. CCC clinic has close to 3,000 patient visitsannually with an average of 50 patients per day. The Division ofInfectious Diseases provides inpatient and outpatient consultationregarding the diagnosis and management of all types of infectiousdiseases. The service is supported by outstanding clinicaldiagnostics laboratories, which provide state-of-the-art techniquesfor rapid diagnosis of infectious diseases. Our staff of providers,Psychiatry, fellows, Psych Residents, social worker, Nutritionist,Pharmacy Liaison, APRNs, RNs, MA/MAAs, a Case Manager and a DataManager who provides compassionate care, excellence in teaching andinvestigations in clinical and laboratory research. CCC is RyanWhite funded. 75% are bilingual with Spanish being their primarylanguage. 80% of our patients have Health coverage under Medicaid.

Our specialists are skilled at treating many infectious conditions,including: Conditions such as HIV infection, Hepatitis, fever ofunknown origin, recurrent infections or rashes of unknown type ororigin, Influenza, Opportunistic infections in patients who areimmunosuppressed due to acquired or congenital immunodeficiency,transplant or other medical condition. CCC guides patients throughthe health system, including appropriate referrals for services toother health professionals.

Job Summary:

Functioning within thecontext of the framework for professional nursing practice, theCommunity Care Nurse Navigator is a registered nurse experienced inpatient throughput, preventing transitional care gaps, andresolving issues to enhance the quality and continuity of apatient’s or populations health care leading to improved healthoutcomes and equitable care. This role supports the HHC mission toimprove the health and healing of the people and communities weserve. Under provider direction, the Community Care Nurse Navigatorprovides skilled nursing care to patients in a variety of clinicalsettings. Scope of responsibility is characterized by use ofnursing process to assess, plan, intervene and evaluate humanresponses to actual or potential health problems utilizingappropriate practices, standards, protocols and guidelines. Thisposition reports to a Practice Manager.

Job Responsibilities:

• Functions as a member of an interprofessional care team in anexpanded nurse role to help patients transition from the acute caresetting (HH ED or inpatient).

The goals include reducing all-causereadmissions, and inappropriate ED utilization, improving carecoordination for patients during the transitional care period, andultimately improving care quality and access for vulnerablepopulations. This role will be responsible for educating the HHcommunity at large and advocating for resources to enhance patienthealthcare engagement and expand the collaboration andcommunication between(inpatient/ambulatory/outpatient/attending/transitionalcare/specialty care/primary care) providers and care teams for highrisk/complex patients.

• Partners with the inpatient (i.

e. acutecare, IOL, STR) or ED physician and care team to proactivelyidentify potential transitional care gaps for this patientpopulation, and establish a safe transition plan. Key strategiesinclude ensuring a patient/caregiver agreed upon CCC Clinic andurgent specialists scheduled appointment(s) with transportation,verifying patient has necessary DME, finalizing an achievablecommunity medication plan, completing diagnostic workup, educatingthe patient on disease and symptom management, and incorporating apatient-centered home care plan.

• Performs post-hospitalization/EDtransitional care strategies within 24-48h after discharge,including post-discharge phone calls, patient education, symptommanagement, and medication reconciliation, and collaborates withCCC clinic physician and (clinic and community) care team tominimize identified gaps in care.
• Throughout thepost-inpatient/ED transitional care period, facilitates thecompletion of the diagnostic workup, follows up on unresulteddiagnostics, collaborates with homecare, pharmacy, and DME toensure the patient has necessary supplies/medications/resources,obtains necessary authorizations, and schedules additionalconsultant appointments.
• Collaborates with clinic physicians toresolve issues and to advance the treatment plan until the patienthas an established primary care provider.
• In collaboration withthe CCC Clinic physician, assists the patient in identifying aprimary care practice for continued care and facilitates thetransfer of care to that practice
• Documents all communication,transition plan, implemented strategies, and patient outcomes inEPIC.
• As a member of the CCC Clinic completes transitional carestrategies and actions per CMS/Payer guidelines for TransitionalCare Management or other program directives.
• Establishes atherapeutic rapport with patients and demonstrates a commitment toserve as a patient advocate.
• Demonstrates the ability to workindependently as well as collaboratively as a member of the healthcare team in order to provide safe patient care and prompt andefficient service. The Community Care Nurse Navigator providestransitional care strategies to his/her peers/colleagues andpatients based on need/coverage.
• Attends/Leads and activelyparticipates in care team meetings to facilitate a safe transitionplan or resolve a patient issue.
• Establishes evidence-basedstandard work and workflows. Develops and implements processes thatimprove the patient experience. Collects and analyzes patient andprogram level data identifies areas of opportunity, recommendsimprovements/revisions or program development, andleads/participates in the idea/plan implementation.
• Applies thenursing process as appropriate within the context of theorganization’s framework for professional nursing practice andfollowing guidelines established by the team.
• Providesoffice-based nursing care in collaboration with provider,communicates with provider regarding patient needs, nursingassessments, and recommendations, demonstrates independent nursingactions based on assessment and problem identification.

Qualifications

• Bachelor’s Degree required, MSN preferred
• Minimum five (5) years of nursing experience, Inpatient andAmbulatory nursing experience preferred.
• Current ConnecticutNursing License
• BLS Certification
• Obtain CCM/CCCTMcertification within two years of hire We take great care ofcareers.

With locations around the state, Hartford HealthCareoffers exciting opportunities for career development and growth.

Here, you are part of an organization on the cutting edge – helpingto bring new technologies, breakthrough treatments and communityeducation to countless men, women and children. We know that athriving organization starts with thriving employees we provide acompetitive benefits program designed to ensure work/life balance.

Every moment matters. And this is your moment . As an EqualOpportunity Employer/Affirmative Action employer, the organizationwill not discriminate in its employment practices due to anapplicant’s race, color, religion, sex, sexual orientation, genderidentity, national origin, and veteran or disability status.