RN Discharge Navigator – Medical Group

About the role

The RN Discharge Navigator at MercyOne is a key member of the care coordination team, responsible for ensuring patients receive comprehensive, seamless care after hospital discharge or emergency room visits. This role involves collaborating with various healthcare professionals to facilitate patient transitions and coordinate follow-up care.

Responsibilities

• Serve as a consistent care coordinator for MercyOne clinic patients being discharged from the hospital and emergency room.
• Collaborate with the care coordination and clinical teams to ensure patient needs are met and all follow-up is transitioned to the ambulatory care team.
• Identify and eliminate barriers to care to achieve an optimal clinical outcome.
• Serve as a liaison between the patient, providers, care team, family, and other involved parties.
• Serve as a resource for patients needing to establish care with MercyOne Clinics across the region.
• Manage the timely transition and follow-up post hospital discharges or emergency room visits ensuring appointments and follow up visits are scheduled.
• Ensure care documents and discharge notes are accessible to the ambulatory care team to ensure seamless transition and communication.
• Coordinate post hospitalization advanced imaging as needed, supporting communication with ambulatory care teams and ordering or tasking of discharge orders.
• Coordinate with clinic manager for access challenges and concerns to ensure timely follow-up.
• Escalate access concerns to Medical Group leadership.
• Identify and refer patients appropriate for resource referrals including care management, high risk health coaching and community health workers.
• Document all patient coordination activities, education, and other interactions in designated inpatient and outpatient electronic health record systems to assure a timely, complete patient record and effective communication with other members of the care delivery team.
• Avoid hospitalizations, readmissions, and unnecessary emergency room visits through support for patients in establishing care with MercyOne clinics and maintaining awareness of providers with access and limitations.
• Assist with tracking, documentation, and outcome reporting for navigation services.
• Perform other duties consistent with the purpose of the job as directed.

Requirements

• Knows, understands, incorporates, and demonstrates the MercyOne (Trinity Health) Mission, Vision, Core Values, Actions and Promise in behaviors, practices, and decisions.
• Identifies problem areas in need of focused attention and implements actions to drive improved outcomes.
• Coordinates patient care in collaboration with the acute and ambulatory care team across the continuum of care.
• Manages the timely transition and follow-up post hospital discharges or emergency room visits ensuring appointments and follow up visits are scheduled.
• Ensures care documents and discharge notes are accessible to the ambulatory care team to ensure seamless transition and communication.
• Coordinates post hospitalization advanced imaging as needed, supporting communication with ambulatory care teams and ordering or tasking of discharge orders.
• Coordinates with clinic manager for access challenges and concerns to ensure timely follow-up.
• Escalates access concerns to Medical Group leadership.
• Identifies and refers patients appropriate for resource referrals including care management, high risk health coaching and community health workers.
• Documents all patient coordination activities, education, and other interactions in designated inpatient and outpatient electronic health record systems to assure a timely, complete patient record and effective communication with other members of the care delivery team.
• Avoid hospitalizations, readmissions, and unnecessary emergency room visits through support for patients in establishing care with MercyOne clinics and maintaining awareness of providers with access and limitations.
• Assist with tracking, documentation, and outcome reporting for navigation services.
• Perform other duties consistent with the purpose of the job as directed.

Qualifications

• Bachelor’s degree in nursing, health administration or related field required.
• Iowa licensure as a Registered Nurse.
• Minimum of three (3) years in clinical setting.

Skills

• Expertise in the use of performance improvement methodology/tools.
• Knowledge related to software programs such as event reporting systems, government reporting systems, and other appropriate software programs.
• Experience with computer applications such as Microsoft Office Suite (Word, Excel, PowerPoint, Outlook), HealthStream, Intranet, and use of reporting tools.
• Experience with PowerChart/EPIC or similar tool.

Benefits

MercyOne offers a full benefits package including competitive compensation, growth opportunities within the system, and support for personal and professional development.