MAKE YOUR MARK, WHERE CARE MATTERS! Diversicare is a premier provider of post-acute healthcare services with a strong legacy of quality care. We strive to foster a culture of transparency, support, and innovation. Our Mission is to improve every life we touch by providing exceptional healthcare and exceeding expectations . We are proud to provide work/life integration for our team members and offer a comprehensive benefits package.
Diversicare operates 76 centers in ten states primarily in the Midwest, Southeast and Southwest. As direct caregivers, you will play an instrumental role in taking exceptional care of our patients and residents, our most important responsibility. We are seeking compassionate caregivers to assist our patients and residents with activities of daily living. We are committed to providing a supportive and collaborative work environment for our team members. A qualified candidate is responsible for all key accountabilities in a manner that is reflective of Diversicare’s Mission and Core Values: Integrity, Excellence, Compassion, Teamwork, and Stewardship. If you are looking for an opportunity to make a difference in the lives of patients and residents you serve, Diversicare is the place for you.
The Nurse Navigator is responsible for the management and oversight of a specific set of assigned patients to ensure high quality care, reduce the risk of hospital readmissions and smooth the transitions of care over a 90 episode of care in the Bundled Payments for Care
Improvement program Programs. Engage and work with traditional Medicare patients whose DRG matches those included in the company’s Bundling Program.
Support and promote the care redesign program established to reduce the patient length of stay and avoid hospital readmissions as much as possible through nursing assessments, physician consultation and patient/family care plan coordination.
Work with providers including Hospitals, other Centers, and Home Health Agencies to monitor care for the patient and coordinate treatment while in center as well as after discharge.
Review and incorporate in care plan information from nursing assessments, physician integration and provided reports.
Develop trust and rapport with Bundling patients and families when patients are in the Center, to insure access to patients upon discharge home; track patients in the home setting with the goal of preventing hospital readmissions.
Support the prompt identification of the DRG’s for the staff at assigned location in the Bundling program; track assigned patient population over a 90 episode that begins with admission to the SNF participating in Bundling; track the patients and monitor by the assigned DRG.
Act as central point of contact for the patient and family during the 90 day episode
Support assigned Centers as they develop Care Paths and their Quality initiatives designed for certain DRG’s.
Assist in service line development to improve patient care as well as improve the Medicare Beneficiary Experience of Care over the 90 day episode.
Document Case Mgt initiatives for the individual patients as they are identified at admission per company standards.
Track closely patients who are readmitted to the hospital, in an effort to bring the patients back to the Center sooner in an effort to better coordinate care and reduce the hospital readmission length of stay.
Understand the quality and performance measures for Medical Directors and Hospitals
Assist the patient and family to navigate through the health care system over the 90 episode of care.
Oversee the completion of the 90 Day Tracker IT form making sure all episodes are shown on the tracker.
Identify all three sets of quality measures (Hospital Quality Measures, MD Measures, and Episode Initiating SNF’s) are captured on each episode record for all patients included in the Bundled Payment Program who’s DRG’s match those included in the program.
Work with Therapy staff and the other care givers to understand the Care Redesign aspects of the program for the diagnostic categories included in the program.
Develop frequent and period contact questions when patients are in the home environment during the 90 episode of care.
See that the 90 day tracker is documented for all patients who qualify in the bundling program and also to record any Beneficiary Incentives included in the program.
High school diploma or equivalent
Must hold and maintain a current LPN
Minimum two (2) years clinical experience with understanding of post acute care
Minimum three (3) years case management experience in a health plan or provider setting
Current Certified Case Manager certification from the Commission for Case Mgt Certification, preferred
Must be capable of maintaining regular attendance
Basic Computer Skills regarding the use of email, and WORD; processing fax’s and messages, email etiquette
Good customer service skills for patients, families as well as health plans, home health agencies, and hospitals
Ability to remain calm under stress and mediate conflicts over the phone
Good coordination skills and timely follow-up responses to customer groups
Job ID 2019-33319
Type Regular Full-Time
Location Name Oak Ridge Nursing & Rehab Center
Address 100 Elmhurst Drive
Location US-TN-Oak Ridge