Registered Nurse Navigator - Home Health Review

About the Role

The RN Navigator Home Health Review is responsible for monitoring home health patients to ensure they meet CMS criteria for continued services. They act as a patient advocate, providing proactive outreach, and collaborate with primary care providers, physicians, hospitals, family, caregivers, and community healthcare providers to coordinate care and facilitate smooth transitions.

Responsibilities

• Evaluate Home Health Plans of Care (485 form) for medical necessity and compliance with payer guidelines.
• Conduct case conferences with Home Health agencies to assess patient progress and discharge plans.
• Recommend recertification or discharge to PCPs based on assessments and guidelines.
• Utilize MCG Guidelines to optimize care type, frequency, and duration.
• Foster positive relationships with healthcare agencies and clinicians.
• Ensure effective communication across care teams and monitor program success metrics.
• Perform outreach focused on medication adherence, self-management, follow-up, and early detection of worsening conditions.
• Navigate electronic medical records and care management tools proficiently.
• Support discharge processes and document according to CMS and Population Health workflows.

Qualifications

• Bachelor’s Degree in Nursing preferred.
• 3-5 years of clinical experience; home health and care management experience preferred.
• RN license in the relevant state or through a compact license is required.

Skills

• Strong communication, care coordination, and advocacy skills.