JOB SUMMARY:
Candidate will coordinate the activities for multiple programs to include but not exclusive to: Total Joint
program. He/she will manage the surgical patient through the surgical episode of care and will serve as a
single point of contact for the providers of care, patient, and family. Individual will assist in the screening
and assessments of patients referred to the various programs; provide initial assessment, identify
opportunities for optimization, and develop plan of care. Individual will coordinate care with physicians,
ensure communication pertaining to services, and treatment, and prepare the patient for surgical episode.
As needed will provide patient specific education on diagnostic testing, diagnosis, and treatment plan. In
addition to coordinating physician referral, will assist in setting up referrals to ancillary services, tracking
the patient's progress and providing feedback through identified program timeframe.
Maintains excellent communication and follow up with the patient. Establishing and maintaining
relationships with community resources. Assessing barriers to care and assisting patient with referrals to
community resources when necessary. Oversee and provide assistance with discharge planning,
coordinates patient's discharge needs with additional services, as necessary. Participate in community
outreach activities by presenting materials for such programs
REPORTS TO: Nurse Navigation Manager
SUPERVISES: N/A
QUALIFICATIONS:
Current State Licensure as a RN required
Minimum of 2 years clinical experience in a Surgical Hospital, ASC, or Acute Hospital setting
Orthopaedic experience preferred
Patient Navigation/Case Management experience preferred
Excellent customer service skills, understand and demonstrate ability to promptly respond to
request for care, follow up on other requests made by various consumers of the services
Must demonstrate knowledge and competency in the following area: computer literacy, strong
written and verbal communication, assertiveness, flexibility, detail oriented, timely follow up,
organization, diplomacy, and marketing of the program
Able to prioritize patient care needs
Analyzes situations and offers action plans
Ability to work with multiple individuals to coordinate care for patient
Able to function well with changing priorities
Effective communication and presentation skills
Excellent attention to detail and follow through
Self-motivated, able to problem solve and work with minimum supervision
Keeps current in industry changes regarding safety and quality of care initiatives
Monitor effectiveness of own work in accomplishing company initiatives and goals
RESPONSIBILITIES:
Develops and maintains clinical protocols in collaboration with members of specialty program
QAPI committee.
Gathers and verifies pertinent information about the patient's medical, psychosocial, and
functional status.
Works within pre-admission inclusion/exclusion criteria set by physicians and anesthesiologist
within the specialty program. Sends appropriate referrals for final determination/clearance.
Coordinates with patient, pre-admission testing, physician team, anesthesia, PCP and/or specialist
to optimize patient's medical conditions prior to surgery.
Collaborates with members of the medical team to ensure a continuum of care.
Acts as a liaison between the patient, patient's family, physicians, nursing, and ancillary contacted
services.
Provides necessary information and education to the patient and support person for the following:
pre-operative, intra-operative, discharge, and post discharge processes.
Manages deviation from designed care pathway, while coordinating with the physician team.
Effectively manages patients' transition home after surgery. This includes working in conjunction
with patient, support person, physicians & office staff, pharmacy, outpatient physical therapy,
home health agencies, etc. to ensure care plans are followed and possible barriers have been
addressed.
Keeps patient and support person engaged in the plan of care and moving toward the identified
program timeframe for patient outcome goals. Advocates for the patient and the program.
Is involved in the quality assessment and performance improvement initiative for the program.
Assists in tracking and analyzing outcomes data for the specialty program and provides reports to
specialty program QAPI committee as needed.
Measures effectiveness of program and drives improvement throughout process.
Conducts follow-up touchpoints (i.e. phone call, online questionnaire) as determined by the
specialty program and communicates questions and/or concerns to physician.
