Job Overview:This position provides comprehensive care coordination supporting a holistic and longitudinal approach across the continuum related to specific episodes of care.This position assists with informed decision making, collaborating with a multidisciplinary team to allow for timely screening, intervention, and increased supportive care throughout the patient experience. This position provides individual assistance to patients, families, and caregivers to help identify and overcome barriers which may hinder quality, medical, and pscyhosocial patient care.Job Requirements:Associate's Degree in NursingEquivalent experience accepted in lieu of degreeRN, Registered NurseProgressive nursing experience in hospital, ambulatory or home healthStrong customer service and communication skillsAbility to work with Physicians and others and collect data, generate reports, and provide analysis via computers and EMR2-3 years experience Clinical Nursing Experience in the specilaty area for which Navigator position is being hired (ie: orthopedics,cardiac, oncology, etc)2-3 years experience Clinical Nursing Experience in home care preferredJob Responsibilities:Assess the patient's plan of care and develops, implements, monitors, and documents utilization of resources and progress of the patient through their care, facilitating options and services to meet the patient's healthcare needs.Evaluates the medical necessity and appropriateness of care, optimizing patient outcomes. Serves as a liaison for referring physicians and connections to community resources.Assesses clients'/caregiver(s)' activation, literacy level and self-management capabilities. Evaluate patient functional abilities and limitations. Determine if intervention is needed. Assist the patient/family through diagnostic services, treatment and care and monitor clinical progress for defined episodes including transition to post-acute environment. Communicates delays in care, functional status and changes in clinical status to specialist and primary care provider (PCP) and coordinates required follow-up and monitoring.Educates client and family/caregiver(s) on diagnosis,course of care, medication, medication reconciliation and nutrition and moves client toward self-management. Collaborates with the patient and family when setting goals; initiate transition planning and recommends additions to or modification of referring orders. Establish treatment goals that are functional, measurable and patient related. Establish and implement a patient centric plan of care that is aligned with clinical protocols in acute, ambulatory and post-acute environment to achieve treatment goals.Reviews and analyzes model of care clinical pathway process improvement activities for appropriate populations of patients to achieve the optimal clinical, financial, operational, and satisfaction outcomes. Participates in ongoing staff development Establish and promote a collaborative relationship withProvide support for data collection and reporting, as needed, for value based contracts.Other Job-Related Information:Working Conditions:Climbing - OccasionallyConcentrating - FrequentlyContinuous Learning - FrequentlyHearing: Conversation - ConsistentlyHearing: Other Sounds - ConsistentlyInterpersonal Communication - ConsistentlyKneeling - RarelyLiftingTriHealth is an equal opportunity employer. We are committed to fostering a diverse and inclusive workforce.