Specialty Care RN Navigator & Transition Coach

Fairview Health Services; Minneapolis (MN); On-site; USD 80,000 - 110,000; Full time

Benefits offered by this job

Medical/dental/vision

PTO & sick leave

Tuition reimbursement

Job summary

Fairview Health Services is seeking a qualified RN to support specialized care coordination across the health continuum. The role focuses on education, safe transitions, and proactive disease management within the designated medical specialty, collaborating with patients, families and care teams.

The incumbent provides direct patient care in the specialty, develops individual nursing plans, coordinates referrals, and supports program quality through data tracking and education materials.

Qualifications

• 3 years in care coordination or 5 years as an RN with clinical experience.
• MN RN license.
• BLS certification required (American Heart Association or Red Cross), except dept 8901 Ambulatory Care Coordination within 30 Days.

Responsibilities

• Accesses, analyzes, plans and provides follow-up care.
• Facilitates timely referrals and fosters positive relations with community providers.
• Evaluates and documents status and follows patient progress through phone calls, test results and report preparation.
• Evaluates quality of nursing care via patient rounds.
• Provides pro-active disease management using evidence based practices.
• Acts as a liaison between patient/family, medical staff and others involved in treatment, promoting patient centered care.
• Collaborates with appropriate staff to provide coordinated transition of care across the healthcare continuum.
• Facilitates timely referrals and fosters positive relations with community providers.
• Provides direct patient care in the area of specialty.
• Establishes individual nursing care plans.
• Provides education, counseling, medication management, and general health information to patients and patient representatives.
• Triages patient concerns and responds to patient concerns between visits under provider direction, to reduce relapse or inpatient care.
• Functions as a resource to patient care units, outpatient clinics and medical staff regarding the clinical specialty.
• Identifies need and assists in writing and implementing policies and procedures.
• Provides education services to patients and their families and other hospital staff regarding the clinical specialty.
• Serves on task forces and committees related to the clinical specialty.
• Keeps up to date on technological advances and new pharmaceutical products.
• Consults with other areas regarding specialty.
• Assists with research projects which may include collection data, data analysis and evaluation.
• Manages database to track patient outcomes and other specific categories as directed by physician.
• Promotes program and assists with marketing efforts. Oversees or manages prior authorization process and results verification process to ensure positive image.
• Provide effective educational material.
• Serves as a community liaison.
• Performs other duties including Performance Goals developed by manager and employee and reported in the employee’s Performance Review as part of UMPhysicians’ Performance Management tools
• Develops and maintains critical competencies listed in this job description and the competencies drop down list in the employee’s online performance management tool.

Skills

Care coordination

RN licensed

BLS certification

Job description

Fairview Health Services is seeking a qualified RN to support specialized care coordination across the health continuum. The role focuses on education, safe transitions, and proactive disease management within the designated medical specialty, collaborating with patients, families and care teams.

The incumbent provides direct patient care in the specialty, develops individual nursing plans, coordinates referrals, and supports program quality through data tracking and education materials.