Third Party Risk Management Jobs in Rochester, NY

Job Title: Nurse Navigator - Women’s Health

Department: Women’s Health

Location: Monday-Wednesday and Fridays at Ridgeway OBGYN and Thursdays at St. Mary’s OBGYN

Hours Per Week: 40

Schedule: Monday-Friday 8am-4pm

Provides proactive case coordination/patient navigation for patients, including triage management, algorithm management, utilization management and resource management. Organizes services across the continuum from pre-registration through discharge from the Center to affect optimal patient outcomes, achieve continuity and quality of care, reduces cost and provide customer satisfaction. Provides assistance to patients and families through evaluation of social, emotional and financial needs and coordinates and facilitates appropriate resources. Communicates with third party payors, follows Health System policies and procedures, and assist with continually improving the quality and effectiveness of case management/patient navigation.

• Reviews the medical record with referring provider as soon as possible after admission-within the first 12 to 24 hours. Applies utilization review criteria to assess and document appropriateness of admission, continued stay and level of care.
• Interviews patients and/or family members to obtain information about social, emotional, and financial factors which impact health status. Assesses needs for progress along department algorithm of care and continuing care or resource support following discharge.
• Responds to referrals from patients, families, physicians, hospital staff, and community agencies. Collaborates with patient/family and members of health care team to develop appropriate post-hospital plans for continuing care or resource support following discharge. Utilizes all appropriate medical, social, and financial resources available to support the patient/family and to ensure smooth transition to appropriate levels of care.
• Responds to referrals from patients, families, physicians, hospital staff, and community agencies. Collaborates with patient/family and members of health care team to develop appropriate post-hospital plans for continuing care, to initiate referrals.
• Proactively identifies problems with utilization of resources and assures specific tests, consults etc. are done in a timely manner. Feedback is obtained and documented in the patient chart. Forward patient chart to physician for review when problems are identified. Intercedes with appropriate department or attending physician to identify cause. Communicates as needed with Physician Advisor, assures patient is placed on clinical pathway and monitors variances from pathway as appropriate.
• Maintains current information on community resources, third party payors, and managed care environment. Knowledgeable of changing rules/regulations, and policies/procedures. Maintains established departmental policies and procedures, objectives, quality management plan, environmental and infection control standards.
• Maintains appropriate and timely documentation through medical record entries, daily logs, computer entries, and monthly statistics. Prepares and maintains required documentation on each patient.
• Completes worksheets, communicates in a timely manner with physicians and coders, provides necessary statistics for data collection, and identifies case mix issues.
• May provide consultation and education to medical and hospital staff of inpatient and outpatient programs regarding role of case management. This may include appropriate management of resources, discharge planning and complex medical/legal issues.
• Assists in development of new services or policies appropriate to patient needs and consistent with strategic plan.
• Makes referrals to administrative director, medical director, quality management, risk management, infection control, and hospital departments when potential quality problems are identified. Refers to and consults with clinical social worker on patients with complex psychosocial/financial needs. Develops and maintains professional working relationship with medical staff, hospital staff, and coworkers.
• Maintains strict confidentiality at all times.
• Ensures that quality of patient care is maintained by collecting quality indicators and clinical path variance data, as well as identifying data that indicates potential areas for improvement.
• Participates actively on clinical pathway, CQL, and clinical process improvement teams. May act as team member, team leader, facilitator, or recorder.
• Provides services, supports or other assistance in a culturally sensitive manner responsive to the patient/families beliefs, attitudes, language and behaviors.
• Provides care appropriate to each patient.
• Develop and maintain strong working relationships with all key internal stakeholders including physicians and center leadership.
• Ensure strict adherence to all established Unity processes, procedures and standards.

• Current licensure as an RN in the state of New York.

• Graduate of an approved school of nursing, BSN strongly preferred.
• Minimum of five years of experience in a health care setting, of which a minimum of two years has been spent in acute care setting.
• Prior experience in women’s health strongly preferred.

BS: Nursing (Required)

BLS - Basic Life Support - American Heart Association (AHA)

RN - Registered Nurse - New York State Education Department (NYSED)

M - Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects; Requires frequent walking, standing or squatting.

$80,753.00 - $110,292.00

Rochester

14626

Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law.