Job Title: RN Readmission Navigator

Employment Type: Full-time (On-site)

Shift: Monday - Friday, Day Shift
Location: Mercy Fitzgerald Hospital

Position Purpose:

Responsible for driving hospital-wide initiatives to reduce 30-day readmissions and improve patient outcomes, particularly for high-risk populations including heart failure, COPD, sepsis, stroke, and myocardial infarction. This role will proactively identify patients at high risk for readmission, conduct targeted education and coordinate care with inpatient and outpatient providers to ensure appropriate discharge destination. Will also perform post discharge outreach to ensure seamless transition and compliance with treatment plans.

What you will do:

• Oversee proactive identification of patients at high-risk for readmission by utilizing electronic health record analytics and interdisciplinary referrals.

• Collaborates with multidisciplinary teams to assess clinical and psychosocial needs to identify potential barriers in effort to develop a comprehensive discharge plan to mitigate readmission risk.

• Communicates with patient’s acute and ambulatory provider care teams, facilitates patient/caregiver discharge meetings, and provides comprehensive education to support successful transition to next level of care.

• Coordinates post-acute care conferences with post-acute providers including nursing facilities and home health agencies.

• Oversees provider team conferences with patient primary care providers to outline discharge plans as applicable.

• Creates working relationships with primary care providers to provide ongoing readmission education and support to the patient population.

• Establishes collaborative care plans across the acute and ambulatory continuum to ensure patient success in the ambulatory space including updates to patient providers and provider team engagement for patient support and goals of care.

• Participates in all readmission work groups and provides applicable data for review.

• Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies to incorporate into clinical practice.

• Utilizes appropriate conflict resolution, assertiveness, negotiation, and collaboration skills to facilitate patient transition throughout the health care continuum.

• Participates and organizes process improvement projects to decrease readmissions.

• Participates in interdisciplinary rounds with a focus on readmissions.

• Provides metric updates at key meetings as applicable.

• Educates all interdisciplinary teams around readmission reduction.

Minimum Qualifications:

• Graduation from an accredited school of nursing

• Valid RN licensure authorized by the Pennsylvania State Board of Nursing or Compact State.

• At least 5 years of acute care management experience with focus on readmissions, utilization management and/or case management preferred.

Position Highlights and Benefits:

• Comprehensive benefit packages, including medical, dental, vision, mental health, paid time off, 403B, education assistance and voluntary benefits (pet insurance, accident insurance, hospital indemnity and others) available from the first day of employment. 

• Work/Life balance with flexible schedules. 

• Free onsite parking. 

• Our mission and core values are what drive each member of Trinity Health to support each other, communicate openly and respectfully while embracing a culture that nurtures a healing, safe environment for all.  

• Referral Rewards Program

About us:

Mercy Fitzgerald Hospital is a 178-bed teaching hospital located in Darby, Pa., which offers advanced acute care services in Delaware County and Southwest PhiladelphiaConsistently recognized for clinical excellence, Mercy Fitzgerald is proud of our many quality achievements such as: Blue Distinction Center for Cardiac Care, Bariatric Surgery Center of Excellence, Achievement Awards from the American Heart/Stroke Associations and Certified Primary Stroke Center.