Temp to Perm Care Transition Navigator - Days
$197,787–$267,010 year
On-siteFremont, California, United States
Job Summary
Coordinate post-discharge care for patients to reduce unnecessary hospital readmissions by conducting home visits, evaluating conditions and medications, and formulating individualized plans for medication management and specialist follow-up. Collaborate with outpatient providers, case management, and post-acute care teams to prioritize referrals, resolve problems timely, and align teaching plans with other disciplines. Provide education on chronic illnesses, disease processes, and device use while documenting all activities in the electronic medical record system. Act as the client's advocate to improve healthcare decisions and participate in interdisciplinary meetings and community-based activities representing hospital interests.
Required Qualifications
- Graduate of an accredited school of nursing
- Current California RN license
- Bachelor's degree, or a combination of clinical education and/or experience
- Current AHA BLS certification
- Current driver's license
- Vehicle insurance
- Access to a dependable vehicle or public transportation
- Experience with Microsoft Office (Word, PowerPoint, Excel, etc.)
- Experience with Google Suite (Docs, Sheets, etc.)
- Must be willing to work weekends
- Must have effective communication skills to interact with patient and family
- Demonstrates excellent communication skills: active listening; use of open-ended questions; ability to reframe and redirect
- Demonstrates critical thinking skills
- Demonstrates flexibility without over reliance on protocols
- The individual prioritizes and plans work activities, uses time efficiently, and develops realistic action plans
- Achieves timely and efficient care coordination through a multidisciplinary effort with members of the health care team
- Interacts with physicians, and other providers, patients and families to coordinate services for patients' post-hospital care in a timely manner and follow-up to ensure appropriate care is received
- Aligns teaching plan with those developed by other disciplines as a way to ensure care coordination
- Coordinates care in a manner that produces the best patient outcome in an effective and efficient manner
- Acts as the client's advocate by initiating action to improve healthcare, or to change decisions or activities which are against the interests or wishes of the client, while being aware and sensitive to patient rights
- Demonstrates client-centered focus
- Transfers information and provides care to patients in a manner that is therapeutic as well as interpersonally and culturally responsive
- Complies with the ANA Professional Code of Ethics
- Maintains an open, approachable manner, and treats others fairly and respectfully. Preserves others' self-confidence and dignity, and shows regard for their opinions
- Role models integrity and fosters the spirit of teamwork and interdisciplinary encounters by utilizing effective interpersonal skills to resolve conflict
- Demonstrates awareness of, and compliance with, patient safety and regulatory and licensing standards; i.e., Joint Commission, Title 22, OSHA, EMTALA, HIPAA, CMS, HSAG and other service-specific regulations
- Practices within the scope of the California Nurse Practice Act (Section 2725) in all aspects of patient care, promoting safe practice in order to reduce risk
- Adheres to hospital, divisional and unit-based policies and procedures, e.g., attendance and punctuality, chain of command
Desired Qualifications
- Experience in health coaching, motivational interviewing
- Experience and comfort with home visits
- Master's Degree in Health Care Administration or Nursing, or in a work-related field from an accredited college or university
- Two to three years of experience in transitional care
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