Network Navigator PRN, Transition Management Office - VUH

Vanderbilt University Medical Center; Nashville (TN); On-site; USD 48,000 - 62,000; Part time

Job summary

Vanderbilt Health in Nashville seeks a PRN Case Manager to lead patient progression through the care continuum. You will coordinate communications among providers, facilities, families, and transport to ensure timely, appropriate care and follow-up.

This role emphasizes post-acute to acute transitions and collaboration with legal conservators to implement patient care plans. The position supports the nursing philosophy and requires expertise in case management, planning, and evidence-based

Qualifications

• Access patient education and guidance across the care continuum.
• Advanced patient assessment and evaluation in complex cases.
• Implementation and evaluation of evidence-based practices.
• Expert case management in high-pressure environments.
• Strategic treatment planning aligned with patient goals.

Responsibilities

• Lead patient progress through care continuum with outcomes focus.
• Manage post-acute hotline and triage calls to deploy resources.
• Coordinate transfers between post-acute and acute care levels.
• Schedule outpatient follow-ups for at-risk patients and maintain communications.
• Coordinate handovers from post-acute to acute settings with proper documentation.
• Serve as primary customer service rep for post-acute network providers.
• Collaborate with legal conservators on care plan decisions.
• Act as lead to Case Managers and coordinate care progression.

Skills

Access Patient Education

Patient Assessment

Evidence-Based Practice

Case Management

Treatment Planning

Job description

Discover Vanderbilt Health : With eight hospitals and over 180 clinics, we are the region's largest comprehensive academic health system. Vanderbilt Health has a long tradition of providing world-class care to the people of the Mid-South, living out our mission of moving medicine forward through preeminent programs in patient care, education and research. Here you'll find a spirit of collaboration and a supportive community where your expertise is valued, your knowledge expanded and your uniqueness celebrated. We are committed to fostering an environment where talented, compassionate people are united in bringing the most advanced care to our neighbors throughout the region.

Organization:

TMO/UM Team F

Job Summary:

Provides leadership by being actively involved with case management staff to help complex cases and remediating barriers. Collaborates with community resources and consulting with clinical teams to meet the needs of the patient/family in managing challenges related healthcare, including, but not limited to appropriate follow-up care, psychosocial issues, funding/financial benefits to meet short term and long term goals. .

Position Shift

PRN Days (scheduled as needed)

KEY RESPONSIBILITIES

• Leads patient progress through care continuum with outcomes based practice; daily management of communication between providers, facilities, families, and transport.
• Manages post-acute care hotline, triaging phone calls from post-acute facilities/agencies, patients/families that initiates decision tree for deploying clinical resources, or executing a transfer to acute setting based on immediate patient needs.
• Transitions patients to appropriate level of care using alternative interventions to attain patient/family specific goals based on plan of care.
• Establishes outpatient follow-up appointments for patients defined as members of an at risk population, including ongoing communications with ambulatory providers.
• Initiates and receives clear handover from post-acute to acute level of care with conversation, documentation, and follow-up.
• Serves as primary customer service representation for post-acute services for network providers; performs outreach and satisfaction calls when appropriate.
• Works closely with legal conservators in decision making related to execution of the patient plan of care.
• The responsibilities listed are a general overview of the position and additional duties may be assigned.
• Acts as lead to Case Managers in coordinating patient progress through care continuum with outcomes based practice; daily management of communication between providers, facilities, families, and transport.

TECHNICAL CAPABILITIES

• Access Patient Education (Advanced): Demonstrates uppermost levels of patient education in practical applications of a complex nature. Possesses mastery of knowledge, training, and expertise to be capable of successfully delivering treatment planning services across the care continuum. Takes a lead role in complex situations when there is a need to achieve results. Actively participates in outside professional organizations and forums.
• Patient Assessment & Evaluation (Advanced): Demonstrates the uppermost levels of expertise in patient assessment and evaluations in challenging and complex situations. Conducts primary care patient interviews and physical examination. Often takes a lead role in complex patient care situations. Possesses expert knowledge, training and experience to mentor less experienced peers.
• Evidence-Based Practice (Advanced): Recognizes, Implements, and evaluates practice changes based on published research. Demonstrates expertise in applying evidence-based practices to challenging and complex situations.
• Case Management (Advanced): Demonstrates the uppermost levels of expertise in applying case management in challenging and complex situations. Often takes a lead role in highly pressurized situations when there is a need to achieve results. Consistently delivers case management services in a creative and imaginative manner while setting a standard for others. Actively participates in outside professional organizations and forums. Contributes in the development of case management best practices for the organization. Often precepts colleagues.
• Treatment Planning (Advanced): Demonstrates expert level knowledge of treatment planning and possesses mastery knowledge, training, and experience to be capable of successfully delivering treatment planning services. Considers the systemic impact of the plan of care on the organizational outcomes.

Our Nursing Philosophy:

We believe highly skilled and specialized nursing care is essential to Vanderbilt University Medical Center's mission of quality in patient care, education and research. We believe nursing is an applied art and science focused on helping people, families and communities reach excellent health and well-being.

As a Vanderbilt University Medical Center employee, you make a difference to our patients and their families by