Coordinates and guides patients through the continuum of care. Facilitates the patient-physician relationship and coordination of care across the spectrum of services through screening and diagnosis, treatment, education to provide comprehensive, multi-disciplinary quality care. Identifies barriers to care, assists with access issues, develops relationships with healthcare providers, establishes and/or improves communication between providers, patients and caregivers in order to coordinate services within the organization, at outside facilities, and within the community.
Coordinates the continuum of care and reduction of time to treatment across multiple modalities.
Collaborates with patient and clinical team to identify next steps in treatment plan, identifies gaps or barriers to care and provides links to Health System and community resources.
Works to reduce time-to-treatment across multiple treatment modalities as well as ancillary and support services.
Ensures navigation tracking database is up to date. Tracks patient progress and keeps care team members apprised.
Collaborates with physicians and other members of subspecialty disciplines to improve quality of life and clinical outcomes for patients and their families.
Serves as a liaison for referring physicians and their staff.
Meets on a regular basis with clinical members for information sharing and continuing education activities.
Serves as point of contact for patients and families.
Informs and educates patients about their disease and care plan and answer questions throughout the course of treatment in the hospital and community.
Tracks patient's progress along care continuum community, inpatient and post-acute; identifies potential bottlenecks and performs appropriate intervention.
Schedules patient appointments.
Acts as a patient advocate, responds to and works to resolve concerns of families.
Liaises with patients, families, physicians, clinical staff, other departments and specialty practices.
Collaborates with care team to develop and improve patient satisfaction initiatives.
Participates in performance improvement activities.
Ensures the ongoing evaluation and quality improvement of procedures.
Maintains data for metrics on patients navigated, patient retention interventions, patient retention rates, patient satisfaction scores, physician satisfaction scores and timeliness of care.
Communicates and coordinates with care team in the development of tools for optimal patient outcomes and report findings.
Coordinates and participates-in committees as needed/requested, i.e. Quality PICG and Clinical Pathways.
Performs related duties, as required.
ADA Essential Functions
Graduate from an accredited School of Nursing. Bachelor's Degree in Nursing, preferred. Must be enrolled in an accredited program within 24 months of employment, if hired after September 1, 2010 and obtain a BSN Degree within five (5) years of employment date.
Current license to practice as a Registered Professional Nurse in New York State. Certification, preferred. Minimum of three (3) years clinical experience, required.
Previous experience in case management, disease management, quality management or patient education, preferred.
Computer skills including MS Office, preferred
Northern Westchester Hospital