Guides patients through the healthcare system and removes barriers by assisting with access issues, developing relationships with service providers and tracking interventions and outcomes. Coordinates the episode of care for all patients including: coordination with the physician offices to ensure proper screening of patients for high risk medical and functional issues, coordinating specialist appointments for optimization of patients prior to surgery, completion of patient reported outcome forms, ensuring completion of pre-operative H&P, coordination of follow up appointments, and help in coordination of post-operative discharge plan; assesses and identifies high risk patients (medically, functionally, socially) in order to ensure that adequate resources are arranged and clinical pathways are followed in order to optimize patient outcomes prior to surgical intervention; participates in development and implementation of pre-operative educational class, whatever the format may be (in person, web-based, paper), and ensures that educational material is distributed prior to surgical phase of care; assists in educating patients on any remote access monitoring system utilized for the program.
Participates in review of quality metrics in an effort to maximize our outcomes, specifically in relation to discharge disposition and readmission rates; assists in appropriately determining needs for patients at discharge and helps to coordinate service if needed-specifically home health care, outpatient PT, remote monitoring systems, etc.
Acts as a liaison between the surgeons, health care staff, and the patient to ensure a successful episode of care; follows up on patients currently NOT in the Medicare Bundled Programs for a period of up to 90 days and initiates a yearly follow up to ensure final completion of patient reported outcome measures.
Participates in staff education on an individual or group basis as needed; updates nurse manager on changes that could impact care delivery; maintains a knowledge of current changes for joint replacement patients at the federal, state, and local level.
BSN required
Minimum of two years of previous RN experience
Ability to effectively communicate with diverse audiences; strong organization and detail orientation skills; prior experience working in protocol/pathway driven environments; strong critical thinking skills
Previous experience in an oncology environment preferred; care coordination or discharge planning helpful
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