UofL Health is a fully integrated regional academic health system with five hospitals, four medical centers, nearly 200 physician practice locations, more than 700 providers, the Frazier Rehab Institute and Brown Cancer Center.

With more than 12,000 team members - physicians, surgeons, nurses, pharmacists and other highly skilled health care professionals - UofL Health is focused on one mission: delivering patient-centered care to each and every patient each and every day.

The Transitions of Care RN Navigator seeks creative solutions to patient barriers for patients and their caregivers during transitions from hospital to home, to SNF stays and back to home, as well as with home health care. The Transitions of Care RN Navigator supports and works collaboratively with the transitional care management team of nurse care managers to complete all transitions of care outreaches, utilizing clinical skills to identify barriers or gaps to be managed by the nurse/social work care manager and ensure completion of care coordination and post discharge appointments for our highest risk patients of the organization. This position collaborates with the interdisciplinary care team to complete the goal of successful transitions of care outreach and subsequent appointments needed with the ultimate outcome of preventing readmission.

Utilizes tools and documents that support a guided care process, collaborating with patients/families/physicians and other members of the care team toward an effective plan of care during the review of the quality care gaps

• Assists with patient and family’s unmet health and social needs
• Provides effective communications to improve health literacy
• Reviews the care plan based on mutual goals with patient, family and provider’s emergency plan, medical summary, and ongoing action plan, as appropriate.

Supports patient’s adherence to plan of care and progress toward goals in timely fashion, facilitate changes as needed

• Schedules all appropriate follow up appointments with Specialists and Primary Care Physicians (PCP)
• Performs telephonic outreach to patients within three (3) business days of discharge and assures that appropriate follow up visits are scheduled
• Ensures both Primary Care Physicians and Specialists have discharge information the day of discharge and coordination of care with the family
• Ensures effective tracking of test results, medication management and adherence to follow-up appointments
• Maintains patient record keeping & data tracking
• Participates in ongoing metric analysis and identification of data trends
• Effectively communicates problems, concerns, or issues and works to resolve in a timely manner
• Contributes to development of meaningful outcome metrics that measure the impact of business's investments of time and talent by reporting on progress against metrics
• Performs root-cause analysis for all hospital readmissions
• Participates with acute and post-acute providers to develop processes, tools, and programs to reduce avoidable readmissions and improve resident outcomes
• Ensures all planned readmissions are documented and coded as such
• Maintains compliance with all company policies, procedures and standards of conduct
• Complies with HIPAA privacy and security requirements to maintain confidentiality at all times

Performs other duties as assigned

Education:

• Bachelor of Science in Nursing (BSN) (required)

Experience:

• Three (3) or more years of experience in an acute healthcare setting (required)

Licensure:

Active Kentucky Registered Nurse License or compact license with privileges to work in Kentucky