Care Management Nurse - Hospital Based

About The Villages Health
The Villages Health is a patient-centered primary care driven, multi-specialty medical group with over 800 team members. Our unique care model gives us both the time and resources to truly care for our patients, along with a company culture that supports a healthy work-life balance for our team members. Our purpose, mission and vision is to empower Villagers and the surrounding communities to live out their dreams by keeping them healthy and healing them quickly. Together, we are changing the way healthcare is delivered and are making a positive difference in the lives of our patients and the communities we serve. In doing so, The Villages Health is creating America’s Healthiest Hometown.
Responsibilities:
An exempt position responsible for nursing care under the supervision of Physicians and Clinical Manager.
Care Navigation is a collaborative process, which assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet an individual’s health needs, using communication and available resources to promote quality, cost-effective outcomes. The Lead will primarily function as care navigation within the hospital setting coordinating transitions of care, discharge planning and re-admission prevention. The Lead is responsible to coach, mentor and advocate for the Care Navigation Staff. They will be the first line, go-to person for Care Navigation staff questions and/or guidance.

• Identify patients appropriate for Care Navigation in the Inpatient setting.;
• Identifies and plans strategies to reduce patient length of stay and resource consumption within the Care Navigation population;
• Uses customer service principles and techniques to deal with patients calmly and pleasantly ;
• Gathers pertinent health data while reviewing patient's previous records. Populates information fields in the EMR;
• Documents all assessments, plans of care and Care Navigation activities for the Re-Admission Prevention (RAP) Program in a timely manner;
• Ensures effective communication and collaboration with multidisciplinary patient care teams;
• Interacts in a collegial and collaborative fashion with outside clinical staff such as specialists, social workers, and other clinical and nonclinical support staff;
• Emphasizes continuity of care and seamless integration during transitions of care to avoid duplication or gaps in plan of care;
• Monitors patient progress while in the acute care and post-acute care settings. Assist with facilitation of discharge process/transition of care to the appropriate level of care;
• Continue to monitor patient’s progress post discharge in an effort to prevent re-admission to acute care and to maximize outcomes;
• Identify opportunities for health promotion and illness prevention;
• Maintains a comprehensive working knowledge of community resources, payer requirements and network services;
• Acts as patient advocate;
• Provides patient education, monitor of health needs and coordination of community resources. Services may be provided in a variety of setting including clinic, home visits, hospitals or skilled nursing facilities.
• Acts as the Lead for the Care Navigation Team providing a direct resource for the team and facilitating day to day communications regarding specific patient needs, team needs and/or scheduling amongst the team
• Other duties as assigned.

• Current, unrestricted RN license in the state of Florida.
• 4+ years experience in a hospital or acute care setting with direct patient care
• Minimum of 2+ years of Case Management experience; preferably Hospital based.
• Knowledge of medical terminology, anatomy, physiology, and pathophysiology.
• Familiarity with health care systems, electronic medical records, regulations, policies, and functions.
• Understanding of documentation standards.
• Knowledge of equipment, supplies, and material needed for medical treatment.
• Understanding of basic laboratory, procedures including preparation and screening.
• Knowledge of infectious disease management and control and safety standards.
• Strong coaching ability.
• Excellent clinical skills and judgment.
• Excellent written and verbal communication skills, with the ability to build relationships
• Excellent organizational skills
• Strong ability to work autonomously and be self-directed
• Strong critical thinking skills.
• Skill in initiating appropriate emergency procedures.
• Skill in handling a number of tasks simultaneously.
• Skills in diplomacy and tact with all interpersonal interactions.
• Ability to communicate calmly and clearly with patients.
• Ability to use manual dexterity to perform medical treatments.
• Ability to establish and maintain effective working relationships with coworkers and diverse patient populations.
• Ability to perform mathematical calculations for drug dosages.
• Ability to work with computer and effectively use electronic medical records (EMR).
• Ability to work under pressure.

Salary is commensurate with experience.