Nurse Navigator, St. Louis, MS, Visiting Physicians Association

Usmm Saint Louis , MO 63150

Posted 1 week ago

Essential Duties and responsibilities

  • Provides on-site clinical coordination

  • Coordinates the transition of care for patients throughout the continuum to ensure patient needs are met accordingly via case conferencing with providers and continuum partners

  • Collaborates with all continuum partners (providers, VPA/Grace/PSC staff, patients/families, community agencies, clinical liaisons)

  • Serves as an educational resource regarding hospice and home care for providers, patients, and caregivers

  • Perform a needs assessment of very high-risk patients (with their input) to maximize or improve current health status and independence

  • Confirm that appropriate home care, hospice, and other ancillary services are in place and are being delivered as directed by the care team

  • When necessary or as directed, travel to patient locations such as a hospital, skilled nursing facility, an in the home to assess patient needs and status

  • Educate the patient and the caregiver on the importance of care in the continuum; this will enable providers to communicate with each other, identifying gaps in care, reduce hospital readmission, improved outcomes and patient satisfaction

  • Facilitate communication of patient status and plan of care during transitional experiences such as home to hospital, hospital to post-acute care facility, and back home

  • Works closely with all providers [Physicians, Nurse Practitioners (NP), Physician Assistants-(PA)] regarding:

  • Criteria for hospice and home care referrals

  • Case conferencing to coordinate care, improve documentation and communication

  • Patient education materials

  • Assists with documentation to support the eligibility of patient under the care of hospice or home care (which may include chart audit worksheet, Labs, diagnostics, History and Physical, Fast Scale, Mortality Risk Scale, etc.*)

  • Utilize clinical tools such as protocols, physician orders, and care coordination models to maximize patient care.

  • Participates in developing and enhancing tools and educational programs that promote patient services:

  • Provides or arranges for in-services for continuum staff

  • Attends all required meetings (monthly staff, etc.) and in-services

  • Identifies any potential opportunities for improvements within the program/continuum or any needed program development

  • Provides/Coordinates educational opportunities for continuum staff on an as needed bases to include participation in new hire orientations

  • Complete and submit reports and data on a daily, weekly, and monthly basis to track volume and productivity

  • Manages time effectively to ensure all duties and documentation requirements are completed in a timely manner

  • Maintains communication with the Director of Nurse Navigators regarding compliance, job performance and significant patient care issues as they arise

REQUIRED Knowledge, Skills and Experience

  • Active R.N. License

  • 1-2 years of hospice experience

  • Ability to perform extensive telephone assessment

  • Knowledge of Medicare regulations and home care and hospice standards

  • Experience with small group presentations and teaching/training

  • Understanding of adult learning principles

  • Exhibits excellent interpersonal skills

  • Working knowledge of computer programs (email, Word, Excel, PowerPoint, etc.)

  • Must be very structured, organized, very detailed and able to meet deadlines

Preferred Knowledge, Skills and Experience

  • Nurse Practitioner License

  • Home Health and care management experience

  • Leadership and/or marketing experience

Visiting Physicians Association, a national leader in delivering home-based primary care, works with home health and hospice agencies to ensure patients receive continuity of care in the home environment. VPA in-home physicians collaborate with agencies to establish in-home treatment plans and certify the need for services. VPA partners with over 1,000 home health agencies, collaborate with independent and assisted living communities, and works with skilled nursing facilities and hospitals nationally to coordinate services and patient transitions to home care.


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Nurse Navigator, St. Louis, MS, Visiting Physicians Association

Usmm