Network Navigator PRN, Transition Management Office - VUH

Vanderbilt University Medical Center; United States; Vor Ort; USD 70.000 - 95.000; Vollzeit

Zusammenfassung

Vanderbilt Health is seeking an experienced case management leader to actively guide complex patient care across the continuum. You will collaborate with clinical teams, community resources, and families to remove barriers and secure appropriate follow-up and services.

In this role you will oversee post-acute communications, triage needs, and coordinate transitions to the proper level of care. You will serve as a key liaison, improving outcomes while supporting patients and their families

Qualifikationen

• Access Patient Education (Advanced): Demonstrates mastery of patient education across care continuum.
• Patient Assessment & Evaluation (Advanced): Conducts patient interviews and assessments in complex situations.
• Evidence-Based Practice (Advanced): Applies research to improve care in challenging cases.
• Case Management (Advanced): Leads coordination across providers and settings.
• Treatment Planning (Advanced): Develops and adjusts patient care plans.

Aufgaben

• Leads patient progress through care continuum with outcomes-based practice and manages communications between providers, facilities, families, and transport.
• Manages post-acute care hotline, triages calls, and coordinates deployment of clinical resources.
• Transitions patients to appropriate care levels and arranges outpatient follow-up.
• Acts as primary customer service rep for post-acute services within the network and conducts outreach.
• Collaborates with legal conservators in patient care decisions.

Kenntnisse

Access Patient Education

Patient Assessment

Evidence-Based Practice

Case Management

Treatment Planning

Jobbeschreibung

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 pre-eminent 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.

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.
• 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.

The responsibilities listed are a general overview of the position and additional duties may be assigned.

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 bringing compassion and care to those in need of hope and healing.

Please see our current employee benefits offered:

• Affordable High Quality Health Plan Options
• Dental and /or vision plan
• 403 (b) retirement plan
• Paid Time off (flex PTO)
• Tuition Reimbursement and adoption assistance (maximums applied)
• Short-Long term disability
• Subsidized backup childcare
• And many more...
• Ask us about our current inpatient nursing supplemental Pay Program! Achieve the Remarkable: Learn more about VUMC Nursing here.

Core Accountabilities:

Organizational Impact: Executes job responsibilities with the understanding of how output would affect and