Nurse Advisor \u2013 RN ambulatory Yale CARE Center (Coordination, Appointment, Referral & Engagement)
Looking for dynamic, seasoned RNs with excellent clinical and communications skills to support a call center to coordinate complex patient referrals and coordination of services in the Yale CARE Center as our patients transition from inpatient units or the emergency departments.
Please include an up-to-date resume with your application
Current care specialties included: Nephrology/Diabetes/Bone Urology Orthopedics
To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values-integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
SUMMARY The CARE Center Nurse Advisor supports and coordinates complex patient referrals and assists with successful and effective transitions of care from a hospital or emergency department setting. Ensures timely access to appropriate clinical care and seamless coordination of services across the patient 's healthcare continuum. The CARE Center Nurse Advisor will be an integral member of the Yale Medicine CARE Center team. The CARE Center Nurse Advisor coordinates services within the multidisciplinary clinical system resulting in exceptional patient care and clinical outcomes. The CARE Center Nurse Advisor collaborates with Yale Medicine CARE Center leadership to improve patient preparedness for treatment through education and psychosocial support while also facilitating interaction between patients, providers, and referrals as appropriate. The CARE Center Nurse Advisor assists in the development of appropriate educational materials and program monitoring to promote coordination of care and patient satisfaction. The CARE Center Nurse Advisor assists Yale Medicine and YNHH leadership teams with program development, expansion, and successful achievement of programmatic goals. EEO/AA/Disability/Veteran.
RESPONSIBILITIES Assists with all new patient referrals, initiatives, and clinical responsibilities associated with the Yale CARE Center. 1. Serves as a clinical leader, patient resource, and advocate for disease specific pod within the Yale CARE Center specialty program. 1 .1 Maintains excellent understanding of evidence-based medicine and disease entities of specified program. 1 .2 Assists with the establishment of Yale Medicine CARE Center protocols, guidelines, and algorithms for the management of patient within designated disease specific pod. 1 .3 In collaboration with the medical team, coordinates the transitions of care for patients within the designated disease specific pod. 1 .4 Provides accurate, comprehensive assessment of relevant medical history and condition including understanding of patient's chief compliant, review of pertinent laboratory results, mental status , psychosocial support, and nutrition. 1 .5 Assesses patient and family understanding of patient condition, goals of care and ongoing management. 1 .6 Provides patient and families with education regarding their disease process, medications, treatment, and plan of care. 1 .7 Post discharge, works with Care Management and other community resources to ensure efficient transition of care to community healthcare agencies. 1 .8 Provides support to patient caregivers through guidance, direction, and support in the outpatient settings. 1 .9 Documents all patient and family interactions in the electronic medical record according to established protocols. 1 .10 Documents multidisciplinary plan of care and achievement of goals. 1 .11 Processes incoming requests for medication authorizations and refills, pending for provider signature. 1 .12 Provides cross coverage for other specialty areas as needed. 1 .13 Attends and actively participates in staff meetings and trainings. 1 .14 Performs all other duties as requested.
2. Serves as the clinical liaison between patients, providers, resources, and community. Collaborates with specialty providers and specialty teams to address any identified gaps in, or barriers to care; intervenes as appropriate. 2 .1 Monitors and measures progress of interventions and outcomes after hospital or ED discharge. 2 .2 Partners with patients and families in addressing their concerns, issues, desires, and needs. 2 .3 Facilitates the assessment, initiation, and evaluation of patient and family education. Enhances the patient/family quality of life through assessment, teaching, communication, emotional support, and the practice of family centered care. 2 .4 Provides support to enhance communication and coordination between patient/family and the healthcare team. 2 .5 Facilitates appointments for consults and support services within established service standards, including social work, dieticians, physicians, etc. 2 .6 Responsible for outreach efforts establishing and maintaining positive working relationships with physicians, nurses, social workers, rehab services, etc. 2 .7 Upon discharge, evaluates and ensures a safe discharge and transition of care. Maintains responsibility for post discharge phone calls identifying issues or concerns related to patient satisfaction and follows up as appropriate. Develops and implements corrective action as appropriate. 2 .9 Monitors daily reports to identify Yale Medicine patients discharged from the hospital or emergency department who may need follow-up with the specialty practice in order to avoid readmissions. 2 .10 Serves as a patient advocate to resolve problems and/or communicate patient and family needs to appropriate healthcare team member. 2 .11 Assists clinical and administrative leaders with quality improvement processes as they relate to transitions of care and patient access to care. 3. 3 .1 Participates in department specific quality improvement activity relevant to program and role. Assists in achieving objectives for the Yale Medicine CARE Center and support an action plan to accomplish set goals. 3 .2 Participates in continuous performance improvement activities. Collaborates with multidisciplinary team to develop comprehensive plans to systematically document indications, appropriateness, complications, and success of treatment. 3 .3 Supports YNHH High Reliability organizational initiative.
4. Collaborates with providers, nurses, and staff to assess educational needs of patients, families, staff, and community. 4.1 Assists clinic nurses/coordinators with the coordination and provision of community education related to the disease entity of designated program/pod. 4 .2 Functions as an educational resource for schedulers, patients, and their families.
5. Functions as a clinical resource for schedulers in the Yale Medicine CARE Center. Leads the coordination of complex patient referrals by collaborating with the scheduling staff to facilitate the patient's entry into the healthcare system. 5 .1 Supports providers and optimizes efficiencies including pending orders in preparation for scheduled office visits or medication refills. 5 .2 Assumes responsibility for clinical calls received at the Yale CARE Center ; triages calls to disease specific clinic nurses as appropriate. 5 .3 As requested, assists Yale Medicine CARE Center leadership with data collection. Provides clinical support to the scheduling staff including identification of patient 's risk, urgency, and severity of the health problem to align the right care, right provider, at the right time for each patient.
REQUIREMENTS: EDUCATION (number of years and type required to perform the position duties): Bachelor's Degree in Nursing required ; Master's degree in Nursing or Healthcare preferred.
EXPERIENCE (number of years and type required to meet an acceptable level of performance): Minimum five (5) years\u2019 experience in acute or ambulatory care required. Experience in a combination of the following is essential: clinical care, clinical process improvement, outcomes management, case management, and physician relations. Knowledge and understanding of standards related to the Joint Commission certification process preferred. Excellent oral and written communication skills.
SPECIAL SKILLS: Candidate must be able to thrive in a fast paced, complex academic medical environment where the CARE Center Nurse Advisor works as a valued member of the multidisciplinary team. Background in disease specific pod preferred. Must possess understanding of clinical processes, organizational dynamics, and process improvement . Must be self motivated, goal oriented, and able to work independently. Must have the ability to develop relationships and work collaboratively and effectively in partnership with patients, families, physicians, clinical staff, hospital departments, community, and outside organizations. Must have excellent assessment, communication, and organizational skills with the ability to manage and follow through on multiple priorities. Excellent critical thinking , analysis, and assessment skills for successful process improvement planning and monitoring. Proficient in computer and data management.
ACCOUNTABILITY (how this position is held accountable for such as goals achievement, budget adherence, or other areas of accountability): Accountable for ensuring patient needs are met throughout the continuum of care. Assist disease specific program with addressing barriers to care, coordination of services and other psychosocial needs. Responsible for identifying gaps and/or trends in care and assists providers and administration with implementing practice changes that support evident based practice.
COMPLEXITY (describe planning, problem solving, decision making, creative activity, or other special factors inherent in the responsibilities of this position): In personal and job-related decisions and actions, consistently demonstrates the values of integrity (doing the right thing), patient-centered (putting patients and families first), respect (valuing all people and embracing all differences), accountability (being responsible and taking action), and compassion (being empathetic).
LICENSURE/CERTIFICATION: Current State of Connecticut RN license