Registered Nurse, Facility Navigator

Job Description: SUMMARY

• The Facility Registered Nurse Navigator, under the direction and supervision of the Hospice Director, provides patient consultation, assistance and education about VNA Health to skilled nursing facilities, residential care facilities as assigned and direct.
• In addition, initiates and conducts hospice patient admissions and is experienced in nursing, with emphasis on community health and/or hospice education/experience.
• The professional nurse builds from assessments to plan and direct services to meet the needs of individual and families within the facilities.
• The Facility Registered Nurse Navigator is the initial nurse in the patient assessment process and identifies a plan to meet the patient’s immediate needs, then hands off to the assigned RN case Manager to follow with the patient/family.
• The Facility Registered Nurse Navigator respects and promotes the mission, values and vision of VNA Health.

Essential job duties and responsibilities

1. Function cooperatively with referral sources and Community Liaison team to

1. Facilitate referrals to Hospice and responsible for providing accurate, consistent and efficient admissions to hospice patients. 2. Evaluate potential patients and referrals from all sources for their appropriateness and eligibility for hospice. 3. Audit charts within facilities, to ensure compliance and regulations are met for hospice patients in facilities. 4. Consult and collaborate with physicians, discharge planning personnel, insurance Case Managers and other sources to facilitate safe, appropriate discharge and/or establish a coordinated plan of care. 5. Coordinate referral with appropriate agency contact to ensure timely response, admission and/or follow up with referral source. Establish and maintain lines of communication between VNA Health and referral sources. 6. Interview the patient, family, and/or caregiver and discusses the current needs, and any psychosocial factors that are relevant to the plan. Coordinate with Liaisons to complete referral information that includes intake data, essential background information, hospital course, and the plan of care. 7. Identify, coordinate and/or provide ongoing education to assigned referral sources regarding VNA Health services and programs. 8. Attend and participate in ongoing organization meetings, including but not limited to, interdisciplinary team conferences, staff meetings and in-service training. 9. Complete all referral and activity reports as assigned. 10. Develop and maintain relationships that support and enhance the mission of VNA Health and promote ongoing business development. 11. Completes an initial assessment of patient and family to determine immediate hospice care needs. Provides a complete physical assessment and history of current and previous illness(es). Admits to appropriate level of service/care. 12. Assesses and evaluated patient’s status by initiating and documenting the patient plan of care. 13. Uses health assessment data to determine nursing diagnosis. 14. Develops a plan of care that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions. Includes the patient and family in the planning process. 15. Initiates appropriate preventative and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician. 16. Counsels the patient and family in meeting nursing and related needs at the admission visit. 17. Provides health care instructions to the patient as appropriate per assessment and plan. 18. Assists the patient with identifying the needs of activities of daily living with emphasis on safety and optional comfort care. 19. Accountable for assessing financial resources and eligibility under various third party payor sources, Medicare and Medi-Cal.