Transitional Care Navigator - VNA Care

Position Summary: Responsible for the coordination of all hospitalized patients within the VNA Care System; 24 hours per week, Remote role; must be able to come into office as needed.

Reports to: Regional Manager, Transitional Care and Business Development

Functions & Responsibilities:

• Provides excellent customer service both externally and internally in the identification of hospitalized patients from the Home Health, Hospice and Palliative Care census
• Responsible for communicating with inpatient facilities to ensure proper identification of patients to VNA Care.
• Documents all updates regarding hospitalized patients in the agency electronic medical record
• Collaborates with Business Development team on an ongoing basis to ensure strong referral relationships, the need to preserve patient relationships and to develop systems to improve communication between VNA Care and inpatient facilities.
• Collaborates with Clinical Teams to create improved communication of patient information and updates.
• Tracks active patient status to ensure timely discharge to comply with regulations (NOTE: this is to avoid late entry of end of episode patients thus delaying a new referral where needed)
• Responsible for tracking patient updates via multiple systems, including but not limited to CarePort Connect, Referral Portals, Agency Dashboards and HCHB.
• Attends departmental meetings as requested
• Assumes responsibility for personal and professional development.
• Ensures that all activities and operations are carried out in compliance with conditions of participation for all services lines and any and all other regulations, standards and laws which govern the range of services delivered.

• Performs other duties as assigned

Skills and Knowledge:

Education:

• Licensed RN in Massachusetts
• Bachelor’s Degree Preferred
• Computer literacy required.
• Excellent interpersonal, organizational, communication and presentation skills

Experience Preferred:

• Minimum of 2 years experience as a nurse in a clinical setting required
• Minimum of 2 years of clinical experience in an inpatient or home health setting preferred