Patient Navigator - UCSF Care at Home

Job Description

As a Nurse Coordinator with UCSF Care at Home, you will be at the forefront of delivering specialized nursing care to frail and homebound older adults. Our program focuses on geriatric care, symptom management, and seamless transitions from hospital to home. You will be part of a dedicated team that provides essential support, education, and resources to complex and high-risk patients in their own homes, ensuring they receive the best possible care.

Responsibilities

• Provide expert nursing care and support to homebound patients, ensuring their comfort and well-being.
• Collaborate with physicians and nurse practitioners to develop and implement care plans tailored to each patient's needs.
• Monitor and manage patients' symptoms, administering medications and providing necessary treatments.
• Educate patients and their caregivers on self-care, medication management, and disease prevention.
• Facilitate smooth transitions from hospital to home, coordinating with healthcare providers and ensuring continuity of care.
• Maintain accurate and detailed patient records, ensuring compliance with regulatory standards.
• Conduct regular home visits to assess patients' progress, identify any emerging health concerns, and adjust care plans accordingly.
• Liaise with community resources and social services to address patients' non-medical needs, promoting holistic care.
• Participate in quality improvement initiatives and contribute to the continuous development of the Care at Home program.
• Uphold the highest standards of nursing practice, maintaining professional conduct and ethical principles.
  
  

Qualifications

Required Qualifications:

• Three years recent experience as a Registered nurse caring for ill adults and older adults
• Active RN licensure in State of California
• Active American Heart Association CPR Certification
• BSN
• Strong knowledge of Patient Rights & Responsibilities, Joint Commission standards, and Centers for Medicare / Medicaid regulations. Knowledge of Medical Terminology. Strong knowledge of data collection, compilation, and analytical techniques
• Strong skills to comprehend and assess patient's grievances to quickly locate appropriate resource for assistance. In-depth knowledge of the organization and how to get issues resolved
• Knowledge of medical terminology
• Demonstrates communication and problem-solving skills necessary in patient/family and healthcare team interactions
• Demonstrates knowledge of the principals of growth and development over the life-span and incorporates this knowledge into plans of care and/or goals of care
• Excellent written and verbal communication skills
• Skills to work independently in a fast-paced, demanding environment with minimal supervision
• Ability to manage and oversee multiple tasks simultaneously, including high daily call volume
• The flexibility to orient and work at all UCSF locations
  
  

Preferred Qualifications

• Certification in Geriatrics, Palliative Care or Case Management in Nursing
• Experience in inpatient, outpatient or homecare settings
• Experience with telephone triage
• Experience developing workflow procedures and implementing systems to improve operations
• Interest and/or experience working with older adults who may have cognitive difficulties
• Proficiency with EPIC APeX applications
• Proficiency with healthcare insurance and billing
• Bilingual/Multilingual capability
• Proficiency with Windows-based software including Microsoft word, Excel, Outlook. Knowledge of computer systems and software used in functional area
  
  

License/Certification

• Active RN licensure in State of California
• Active American Heart Association CPR Certification