Job Description

Steward Health Care Network (SHCN) takes pride in its community-based care model, which drives value-added tools and services to our communities, patients, physicians, and hospitals across the continuum of care. In addition, Steward Health Care Network promotes care coordination and collaboration within the network in order to provide high-quality, efficient care to patients. With Steward in the community, all residents can be sure that there is a world class doctor close to where they live.

The network is also responsible for the implementation and execution of our managed care contracts, medical management services, quality improvement programs, data analysis, and information services.

Position Purpose:

The RN Navigator works in conjunction with hospital-based staff and is responsible for ensuring the coordination of Steward Health Care Network’s Bundled Payment Program (BPCIA) to drive high quality and cost-efficient outcomes. The position is focused on patient identification, clinical care redesign, optimal discharge disposition planning, patient education and coordination across the continuum of care. The RN Navigator focuses on the coordination and analysis of clinical aspects of care. The RN Navigator works closely with the patient’s clinical team, case management, physical therapy and post discharge planning resources available at the time of discharge to drive optimal patient outcomes using their education and experience in a patient centered environment from an oversight perspective.

  • Implements BPCIA Program strategy in conjunction with Steward Hospitals and patient centered environments with a focus on driving and optimizing high quality, cost-efficient care, including but not limited to:
    • Patient identification
    • Performs and analysis of patient centered assessments including SDOH barriers and readmission risk
    • Participates in multidisciplinary rounds
    • Reviews and monitors care across the continuum
    • Medication reconciliation
    • Patient (and caregiver/family) education
    • Discharge disposition planning and implementation
  • Develops strong working relationships with key hospital leadership personnel and post-acute care partners
  • Uses data and clinical expertise to drive program performance communicating with key internal and external stakeholder’s to assist in continually improving clinical care and performance using best practices.
  • Meets regularly with internal / external staff to review data and develop strategies that drive continuous improvement.
  • Works with management and is responsible for monthly performance targets based on real time metrics as well as claims based data
  • Understands and is able to articulate of staying within the Steward Network to patients and families while maintaining a patient’s right to choose
  • Educates hospital team on specialty BPCIA programs and collaborates on performance improvement opportunities
  • Assists key stakeholders in implementing care via partnered and preferred agencies.
  • Tracks feedback received from patients, families and others regarding programs and preferred facilities for process improvement opportunities.
  • Completes documentation in Care Radius per departmental expectations.
  • Is integral in working with SHCN’s IT department to ensure the maintenance of care management databases and use of care management documentation systems. Proactive about identifying and advocating for system enhancements that may be required to deliver high quality care management services. Collaborates with IT teams to implement, test, and deploy system upgrades and enhancements.
  • Responsible for the implementation of Care Improvement (LEAN) initiatives and principles related to achieving quality and patient satisfaction outcomes.
  • Demonstrates leadership that creates and fosters a culture of continuous improvement.
  • Performs all job functions in compliance with applicable federal, state, local, and company policies and procedures.
  • Other duties as assigned.

Education / Experience / Other Requirements

Education:

  • Certified RN
  • Minimum 4 year degree
  • Broad clinical background desired

Years of Experience:

  • Minimum three years’ experience in care management role (preferably in a hospital setting)
  • Ability to analyze programs for effectiveness and care coordination impact

Work Related Experience:

  • Self-starter able to work as an individual contributor and as part of a team
  • Demonstrated ability to interact with and influence internal and external key stakeholders
  • Helping promote the SHCN ACO network and growing programs

Specialized Knowledge:

  • Excellent critical-thinking, observation, written /verbal skills, problem-solving, and analytical skills.
  • Ability to lead and motivate others to execute a plan in a rapidly changing environment.
  • Ability to work collaboratively with health care professionals at all levels to achieve established goals and improve quality outcomes. Highly organized and ability to work autonomously.
  • Knowledge of governmental rules and regulations and hospital standards
  • Strong current working knowledge of Accountable Care Organization (ACO) desirable.
  • Knowledge of leading practice in clinical care and payer requirements.
  • Familiarity with the compliance and regulatory standards governing health plans and patient care including NCQA, URAC, federal, state, and other regulatory requirements.
  • Ability to use Microsoft Office tools including Word PowerPoint, Excel, and Outlook;
  • EHR proficient.
  • Current State RN license.
  • Valid driver’s license and an insured vehicle in proper working order for local travel.

Application Instructions

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