Candidate will coordinate the activities for multiple programs to include but not exclusive: total joint, spine, bariatric, cardiac programs. The role will manage the surgical patient through the surgical episode of care and will serve as a single point of contact for the providers of care, patient, and family. Individual will assist in the screening and assessments of patients referred to the various programs; provide initial assessment, identify opportunities for optimization, and develop plan of care. Individual will coordinate care with physicians, ensure communication pertaining to services, and treatment, and prepare the patient for surgical episode. As needed will provide patient specific education on diagnostic testing, diagnosis and treatment plan. In addition to coordinating physician referral, will assist in setting up referrals to ancillary services; tracking the patient’s progress providing feedback through identified program timeframe.

Maintains excellent communication and follow up with the patient. Establishing and maintaining relationships with community resources. Assessing barriers to care and assisting patient with referrals to community resources when necessary. Assisting patient in completing pre- authorization information. Oversee and provide assistance with discharge planning, coordinates patient’s discharge needs with additional services as necessary. Participates in community outreach activities by presenting materials for such programs: total joint, spine, bariatric, cardiac programs. at health fairs and other community-based service groups.

QUALIFICATIONS:

• Current State Licensure as a RN required.
• Minimum of 3 years clinical experience in a Surgical Hospital, ASC, or acute hospital setting.
• Relevant specialty (surgical) experience required.
• Excellent customer service skills.
• Demonstrates ability to promptly respond to request for care, follow up and other requests made by various consumers of the services.
• Able to prioritize patient care needs.
• Analyzes situations and offers action plans.
• Ability to work with multiple individuals to coordinate care for patient.
• Able to function well with changing priorities.
• Effective communication and presentation skills.
• Excellent attention to detail and follow through.
• Self-motivated, able to problem solve and work with minimum supervision.
• Keeps current in industry changes regarding safety and quality of care initiatives.
• Monitor effectiveness of own work in accomplishing business unit and company initiatives.
• Knowledgeable in-patient safety, quality of care, patient and family centered care initiatives
• Must demonstrate knowledge and competency in the following area: computer literacy, strong written and verbal communication, assertiveness, flexibility, detail oriented, timely follow up, organization, diplomacy and marketing of the program.

ADDITIONAL PREFERRED QUALIFICATION:

• BSN preferred
• Previous Patient Navigation experience preferred.
• Case Management experience preferred.

RESPONSIBILITIES:

• Serves as a single point of contact for providers of care, patient, and
• Develops and maintain clinical protocols in collaboration with sponsoring
• Manages any deviation from designed care pathway, coordinating with surgeon and primary care physician.
• Coordinates with preadmission testing/PAT and ANRP/Anesthesia/Primary Care Physician and/or surgeon to optimize patient’s medical conditions prior to surgery
• Collaborates with members of the medical team to ensure a continuum of care for the program patient.
• Works collaboratively and acts as a liaison between the patient, patient’s family, physicians, nursing and ancillary contracted services.
• Gathers pertinent information about the patient’s medical, psychosocial, and functional status
• Works within criteria set by the pre-admission/registration processes identified by the anesthesia provider and surgeon, sends appropriate referrals to anesthesia/surgeon for final determination when information warrants.
• Implements necessary changes in coordination with the medical team to improve patient quality of care and optimization pre-operatively.
• Provides necessary information and education to the patient and support person for the following: pre-operative, intra-operative, discharge and post discharge processes.
• Serves as the patient point of contact pre-operatively and post-operatively, if patient symptoms worsen. This requires on-call responsibilities.
• Identifies barriers to the plan of care and intervenes as
• Manages the patients’ transition from the facility to other This includes working in conjunction with home support person, outpatient physical therapy, home health agencies, etc. to ensure the patient is following the coordinated care plan.
• Keep patient and patient family engaged in the plan of care and moving toward the identified program timeframe for patient outcome goals. Be an advocate for the patient and the
• Works with physicians to develop and maintain clinical
• Participants in the quality assessment and performance improvement initiative for the
• Tracks and analyze outcome data for the program and provide reports to program committee and Quality Assessment and Performance Improvement Committee, quarterly.
• Tracks outcomes and referrals and treatments
• Measures effectiveness of program and drives improvement throughout process
• Conducts discharge phone calls for program patients
• Reviews clinical progress of patients and coordinates communications to referring, consulting and primary care physicians.