Registered Nurse (RN) Orthopedic Navigator
The Registered Nurse (RN) Orthopedic Navigator will utilize the nursing process to provide optimal quality and continuity of healthcare services from the pre-operative setting through a ninety day episode of care. The Navigator will develop care plans that are specific to each patient's physical, mental and social needs, based upon pre-surgical assessments. The plan of care will be implemented and modified, as needed, throughout the transition of care to ensure the patient's well-being and achievement of desired outcomes. The Navigator will work collaboratively as part of a multi-disciplinary team to provide patient and family education, communication with health providers, and coordination and facilitation of services within an episode of care.
Responsible for managing a group of Medicare orthopedic patients throughout a ninety day episode of care as part of the CJR Bundled Payment Care Initiative.
Gather clinical information from the patient records (EMR) and perform telephonic health assessments to determine risk stratification. This includes a comprehensive assessment of physical, emotional, psychological, and environmental needs of the patient.
Document clinical assessments and care plans in the bundle program information system (PMI).
Educate the patient and caregiver of the process and expectations of the health care delivery system throughout the course of care including but not limited to care in AR, SNF, LTAC, Home Care settings.
Develop and implement care plans throughout the transition of care to ensure the patients well-being.
Collaborate with multidisciplinary team members in the acute, post-acute and outpatient settings to identify patient needs such as home health care, DME, physical therapy and community services.
Follow-up on patients at predetermined intervals and as needed based upon patient status, telephonic and on-site.
Complete and submit all required documentation within established guidelines.
Evaluate plan of care and revise on ongoing basis as determined by patient's health status and communicate changes to all other disciplines involved in the patient's care.
Communicate with providers and multidisciplinary care team members to facilitate transition of services throughout the continuum of care.
Identify gaps or barriers in treatment plans to ensure that discharged patients receive appropriate resources and services.
Understand the Bundled Payment Program design, implementation, management, monitoring and reporting requirements.
Remain flexible and responsive when changes occur in patient activity and workload.
Adhere to scope of practice for the Registered Nurse per state regulatory guidelines.
Maintain confidentiality of all patient information per HIPPA and BRRH guidelines.
Graduate of an accredited nursing school (AD in Nursing, RN Diploma, or BSN)
Current Florida license as a Registered Nurse
BLS certification by the American Heart Association
Experience with the Bundled Payment Program strongly preferred