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.

icon no score

See how you match
to the job

Find your dream job anywhere
with the LiveCareer app.
Mobile App Icon
Download the
LiveCareer app and find
your dream job anywhere
App Store Icon Google Play Icon

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
Nurse Practitioner Housecalls Per Assessment St Louis And St Charles Counties MO 2500 Sign On Bonus For External Candidates

Unitedhealth Group Inc.

Posted 3 days ago

VIEW JOBS 3/18/2019 12:00:00 AM 2019-06-16T00:00 Serving millions of Medicare and Medicaid patients, Optum is the nation's largest health and wellness business and a vibrant, growing member of the UnitedHealth Group family of businesses. We're also the career home for Nurse Practitioners who are eager to bring compassion and passion, energy and focus to their work every day. Join us and you'll discover a chance to build meaningful relationships with the patients, their families and the health care providers who are responsible for their care. Primary Responsibilities: * Conduct in - home assessments on health plan members, including past medical history, review of symptoms, physical examination, medication review and depression screening * Responsible for checking vitals, conducting a physical exam that includes monofilament test, urine dipstick and foot exam (as appropriate) * Identify diagnoses to be used in care management and active medical management in the furtherance of treatment * Formulate a list of current and past medical conditions using clinical knowledge and judgment and the findings of your assessment * Communicate findings in your assessment that will be used to inform the PCP of potential gaps in care * Educate members on topics such as disease process, medication and compliance * Comply with all HIPAA regulations and maintain security of protected health information (PHI) Since this position involves in-home visits, the ability to work autonomously and extensive travel will be required. You should also be comfortable working with geriatric patients who have a variety of health complications. Required Qualifications: * Active, unencumbered license to practice nursing in the assigned state * Nurse Practitioner Certification from either the ANCC, AANP or AACN as Adult, Geriatric, or Family NP * 1 year of clinical experience in highest level of education OR 3 years of experience as a Registered Nurse * Ability to obtain DEA licensure / prescriptive authority post - hire in states where applicable * Ability to spend at least 1 hour with a member in their home, which may be in understaffed or remote areas, in the presence of pets or individuals who are tobacco users * Ability to lift a 30 pound bag in and out of car and to navigate stairs and a variety of dwelling conditions and configurations * Access to reliable transportation that will enable you to travel to client and / or patient sites within a designated area Preferred Qualifications: * Experience in Gerontology, Cardiology, Internal Medicine or Endocrinology * Home care or home visit experience * Excellent administrative and organizational skills and the ability to effectively communicate with seniors and their families * Computer literate and able to navigate the internet Transforming health care and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life's best work.(sm) PLEASE NOTE The sign on bonus is only available to external candidates. Candidates who are currently working for a UnitedHealth Group, UnitedHealthcare or a related entity in a full time, part time, or per diem basis ("Internal Candidates") are not eligible to receive a sign on bonus. Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. Job Keywords: Nurse Practitioner, NP, long term care, LTC, Assisted Living, Nursing Home, Primary Care, Assessment, Home Care, House Calls, St. Louis, St. Charles, MO, Missouri Unitedhealth Group Inc. Saint Louis MO

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