Case Manager-Transition Navigator - Heart Care Navigation

Scope of Position/Position Summary:

The Heart Care Navigation (HCN) Liaison improves outcomes by reducing all cause readmissions and coordinating episodes of care among patients in a defined population or disease process. The primary focuses are (1) on the coordination and delivery of efficient, effective, compassionate, patient centered care and safe transitions across the care continuum and (2) providing care navigation services to the cardiac population. The Heart Care Navigation Liaison monitors the patient care process and physiological needs; educates, documents, communicates, and collects data to evaluate and assure patient/family readiness for discharge. The HCN Liaison facilitates the lateral integration of the care team, collaborating with physicians, nurses and other staff across the continuum to provide comprehensive disease management, assessment, treatment, education, and follow-up evaluation for patients; and, to communicate the plan of care in coordination with post-acute care settings. The HCN Liaison ensure a fluid integration of all willing patients discharging with a primary diagnosis of HF and are followed for Care Navigation services in the Ambulatory space. Serves as a liaison with post-acute partners as determined by the Heart Leadership team. The HCN Liaison will manage patients and facilitate care navigation through the format of telephone calls in a post-acute setting.