RN Transitional Care Navigator-Post Acute

Swedish Hospital; Evanston (IL); On-site; USD 58,000 - 89,000; Full time

Job summary

Swedish Hospital in Illinois seeks an RN Transitional Care Navigator to lead case management and care coordination across settings. This full‑time role focuses on high‑risk patients, utilization management, and safe care transitions, coordinating with clinicians to improve cost and quality outcomes.

Responsibilities include developing individualized care plans, guiding patients through the health system, and collaborating with social work for resources.

Qualifications

• Bachelor’s degree in healthcare administration or nursing required/preferred.
• 3+ years of utilization review, discharge planning, or case management preferred.
• Nursing experience in home or ambulatory settings is beneficial.

Responsibilities

• Guide high‑risk patients through the health system from diagnosis to follow‑up.
• Create individualized care plans using evidence‑based guidelines.
• Partner with the care team to ensure timely decision making and discharge planning.
• Coordinate across departments and with community outreach for safe transitions.
• Educate patients and families on resources, medications, and goals of care.
• Monitor utilization and outcomes, aiming to reduce readmissions and cost.

Skills

Case management

Care coordination

Utilization management

Discharge planning

High-risk patients navigation

Interdisciplinary collaboration

Education

Bachelor's Degree Healthcare Administration

Bachelor's Degree Nursing

Tools

EMR

Microsoft Office

Job description

Hourly Pay Range:

$41.86 - $64.88 - The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.

Position Highlights:

Position: RN Transitional Care Navigator

Location: Glenview/Highland Park Regions

Full Time: 40 hours per week

Hours: Monday-Friday, 8:00a-4:30p

Possible weekends in the future; coverage for team member's time off

A Brief Overview:

The RN Transitional Care Navigator (Population Health) is responsible for the case management, care coordination management, and utilization management of his/her population of patients across multiple care levels and settings. Serves as a catalyst to promote patients understanding their diagnosis, treatment options, and available resources and ensure that they are connected with the optimal resources across the continuum of care. This role will coordinate and facilitate smooth and safe care transitions while ensuring quality cost-effective patient outcomes. Serves as a liaison between their patient population and all other providers. Will be responsible for key metrics of success, which include improving the overall cost of care, length of stay optimization, reduction in excess days, reduction in SNF utilization and improvement in SNF care transitions, reduction in 30‑day readmission rate and ED utilization.

What you will do:

• Guides high-risk patient and family through the health system from diagnosis, testing, treatment and follow‑up care to assist patients with navigating the continuum of care. Eliminates barriers to patient's access to health care services and facilitates continuity of care/care coordination.
• Establishes and documents an individualized plan of care for assigned patients using evidence‑based treatment guidelines considering the patients individual health goals with a focus on wellness, health management, disease prevention and chronic disease management.
• Partners with the healthcare team to ensure clinical decision‑making, implementation of recommendations, and discharge planning are timely and appropriate.
• Performs daily coordination between multiple departments, multi-disciplinary team, medical clinics, and community outreach to gain knowledge of patient, assure patient safety, smooth transitions of care, and manage utilization and total cost of care.
• Acts as advisor/educator by partnering with social work in providing emotional support including goals of care and counseling. Provides and/or arranges clinical education including medication management, community resources, financial resources, and expert guidance to patients and families to promote their ability to understand and meaningfully participate in the healthcare process and personal decision‑making.
• Facilitates appointments for appropriate consultations and support services within established protocols.
• Completes Utilization Management for assigned patients.
  • a) Applies Milliman Care Guidelines (Indicia) criteria to monitor appropriateness of admissions and continued stays and documents findings based on Department standards.
  • b) Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas.
• May need to travel to visit the patient at home from time to time.
• Available to his/her assigned patient population and participates as part of a call coverage structure.
• Participates in the collection and analysis of data to identify under/over utilization; improve resource consumption; promote potential reduction in cost; and enhance quality of care consistent with organization strategic goals and objectives.

What you will need:

• Bachelors Degree Healthcare Administration Required
• Bachelors Degree Nursing Preferred
• 3 Years Minimum three (3) years of utilization review, discharge planning, case management or disease management preferred. And
• Nursing experience in home services, ambulatory services working with high-risk patients beneficial. And
• 2 Years 2+ years of clinical nursing experience preferred
• Adheres to and practices in alignment with contemporary standards of care as established by leading professional organizations, including but not limited to the American Academy of Ambulatory Care Nursing (AAACN), the American Case Management Association (ACMA), and the Case Management Society of America (CMSA).
• Interacts with and contributes to professional development of peers and other health care providers as colleagues. Shares knowledge and provides feedback with peers to contribute to an environment supportive of clinical education.
• Knowledge of InterQual or MCG criteria preferred
• Clinical certification, such as case management certification, is beneficial.
• Able to communicate and work collaboratively with a range of stakeholders and team members
• Knowledge of community resources
• Experience with Microsoft Office Suite
• Strong interpersonal and oral communication skills
• Strong computer and data entry skills
• Experience with Electronic Medical Record (EMR) platform preferred
• Proven l