Summary 

The Transitional Care Nurse Navigator assumes responsibility and accountability for the management of resources through interdisciplinary collaboration to achieve optimal patient outcomes and reduction of read missions. The nurse navigator's goal is to have a patient who is better prepared for home life and disease management with the appropriate follow up planned into their post-discharge schedule.

Primary Duties and Responsibilities

• Convey the purposes and services of program initiatives offered by MSMHC Partners in Care to perspective user populations and refer appropriate patients.
• Perform assessments of patient's needs and abilities to care for themselves, readmission risk, needs for followup post discharge.
• Provide patient education on disease process, medications, and self-care management; supply patient with educational materials to re-enforce self care monitoring.
• Ensure timely care by reviewing care orders, medication and assisting with planning of diagnostics & interventions.
• Coordinate referrals to specialists, support services
• Assist patients and their families to understand the care needs and instructions by translating health care records and doctor's orders to make them more patient friendly and easier to follow.
• Assist coordination of post discharge follow up appointments and needed medication and supplies.
• Coach patients and family in follow-up to chronic health conditions and self-management strategies presented during hospitalization and planned clinic/health care provider visits.
• Document activities, service plans, and results in an effective manner while strictly adhering to the policies and procedures in place
• Assist patients and family by consulting with case management to access health related services, including but not limited to: obtaining home health care, providing instruction on appropriate use of the resources available, overcoming barriers to obtaining needed medical care and social services
• Build and maintain positive working relationships with the patients, family members, providers, case managers
  and other health agency representatives
• Continuously expand knowledge and understanding of community resources, services and programs
• Maintain data records of patients seen and provide follow-up phone calls at planned intervals.
• Maintain spread sheets for calculation of data from routine visits with patients, including but not limited to volume seen, readmission rates and information needed on core measures
• Participate in patient interdisciplinary rounds
• Other duties as assigned

Minimum Qualifications:
Education
BSN required

Experience
3-4 years Nursing experience in dealing with chronic illness patient care and cardiac care required
Licenses and Certifications
-RN license in Maryland in good standing required and
-BLS certification required

What We Offer

• Culture- Collaborative, inclusive, diverse, and supportive work environment.
• Career growth- Career mentoring to help you pursue your passions and gain skills to enhance your value.
• Wellbeing- Competitive salary and Total Rewards benefits to help keep you happy and healthy.
• Reputation- Regional & National recognition, advanced technology, and leading medical innovations.