Care Transition Navigator
The Transitions Navigator utilizes advanced nursing skills to coordinate the clinical care for a designated patient population across the continuum of care. The responsibilities include but are not limited to clinical effectiveness, identification of psychosocial barriers, discharge coordination, care coordination and core measure documentation. The transitions navigator interacts with the unit case manager, unit social worker, medical, nursing and ancillary staff to facilitate quality based, cost effective patient outcomes to insure the patient effectively transitions to the right place at the right time.
Job Specific Responsibilities
1. Transition of Care Planning
• Identify patients with extended length of stay
• Utilizes EMR documentation for transition status and centralized documentation of interventions.
• Identifies actual and potential delays in service or treatment and works with the appropriate individuals, including but not limited to, Social Work and Case Management.
• Collaborate with multidisciplinary staff to ensure patient/family has received appropriate information and education prior to transition to the next level of care.
• Collaborate with unit Social Work and Case Management to Identify and solve problems related to discharge needs, implement a plan of care and coordinate a safe and timely discharge.
• Advocate, mediate and negotiate to formulate a cohesive plan for maintaining or enhancing patient’s health status and moving the patient safely to the home or next level of care.
2. Professional Development • Stay abreast of expected length of stay. Attends appropriate clinical and professional organizations, workshops and meetings.
• Stays abreast of community resources available to facilitate safe patient transitions of care.
• Remains current on clinical advancements related to patients with extended length of stay.
• Proactively seeks to understand areas/roles outside of immediate area/role within department
3. Other • Demonstrate customer focused interpersonal skills, utilizing problem solving process and critical thinking.
• Performs other duties as assigned
• Collaborates with health care team on the plan of care, referrals and ongoing needs of the patient. Participates in communication and coordination of this plan of care with the social worker and case manager and other health care team as necessary.
• Improves quality through reduction in treatment delays, use of clinical pathways and monitoring of quality indicators.
• Collaborates with the health care team to identify resources available for the patient/family; provides. Coordinates the provision of education for patient and family regarding the plan of care and health care needs. Assures implementation and monitors pathways and patient care protocols.
• Helps to develop, revise and evaluate tools needed to facilitate care coordination and patient care standards. Participates in process improvement and evaluation of patient outcomes for specific patient populations. Participates with team in quality improvement activities. Completes and submits statistical data in a timely manner.
Preferred: Case Management
Preferred: Pediatrics nursing experience
Required: Two-year Associate's degree or equivalent experience
Preferred: Four-year Bachelor's degree or equivalent experience
Specific Knowledge, Skills and Abilities
Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions. Identify and understand issues, problems, and opportunities; compare data from different sources to draw conclusions; use effective approaches for choosing a course of action or developing appropriate solutions; take action that is consistent with available facts, constraints, and probable consequences. Meet patient and patient family needs; take responsibility for a patient's safety, satisfaction, and clinical outcomes; use appropriate interpersonal techniques to resolve difficult patient situations and regain patient confidence. Develop and use collaborative relationships to facilitate the accomplishment of work goals. Take prompt action to accomplish objectives; take action to achieve goals beyond what is required; be proactive. Deal effectively with others in an antagonistic situation; use appropriate interpersonal styles and methods to reduce tension or conflict between two or more people. Set high standards of performance for self and others; assume responsibility and accountability for successfully completing assignments or tasks; self-impose standards of excellence rather than having standards imposed. Assimilate and apply new job-related information in a timely manner. Clearly convey information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message.
Licenses and Certifications
Required: Active RN License in the state of TX
Preferred: Accredited Case Manager (ACM) or Certified Case Manager (CCM)
and doctors who treat who give the nurses lots of autonomy and respect. I also love the patients and families we have. They are very involved in their child’s care and appreciative of what we do for them.
Kelsei, RN, BSN, CPN