Nurse Care Navigator (Remote)

PURPOSE AND SCOPE:

Responsible for coordination and management of evaluation of kidney transplant patients in the pre-transplant phase. TCN RN will work in collaboration with their TCN Scheduler to schedule, confirm and execute testing. TCN will review the results of testing (see responsibilities) and update EMR per hospital policy and procedure. TCN will review all testing and elevate abnormal testing to designated Transplant Center physician. TCN will also collaborate with the Transplant Center team to accomplish pre-transplant evaluation where appropriate. TCN will attend meetings with Transplant Center when needed and present patients at selection conference for decisioning on candidacy.

PRINCIPAL DUTIES AND RESPONSIBILITIES:  

• Clinical review of Incoming Referrals to ensure they meet the transplant Center Evaluation Guidelines
• Request and place orders for Referral Testing per Protocol for acceptable candidates
• Consent patient and secure “consent for transplant evaluation” per Transplant Center Protocol (needed to bill the transplant center for testing and services)
• Provide CMS transplant education per Transplant Center Policy
• Assist patient in completing Health Maintenance Screening tests
• These are orders for testing that is not on the “standard list” of UNOS-required labs and/or not explicitly outlined in transplant center evaluation testing guidelines.
• Schedule health screening tests (hospital services/external partners)
• Need to identify local partners (e.g. local radiology centers, local cardiology clinics) who can undertake the necessary testing:
• Dental – Assist patients in obtaining dental care as needed per Transplant Center policy
• There may be “special case” scenarios for patients with specific insurance.  E.g. some commercially insured patients may require testing to be done at the transplant center parent hospital.  Need to develop a clear algorithm with communication pathway with transplant center administrator/billing personnel to address questions.
• Review results and review abnormal testing with designated Transplant Center physician or designee.
• Confirm patient intent/attendance (dialysis clinic SW)
• TCN will periodically need to communicate/coordinate with FKC clinic MSW about upcoming appointments.
• TCN will need to communicate with FKC MSW about patients that are proving to be difficult/impossible to schedule/re-schedule – Approach for escalation to attending nephrologist to review if patient really is a candidate for referral or whether there is a psychosocial barrier that has been uncovered.
• Coordinate billing & reimbursement for testing with transplant center Financial Coordinator
• Familiarization with key billing codes for testing to ensure this is billed through the transplant center and not billed to the patient.
• Key part of patient consent: Any follow-up testing because of an abnormal test is not part of the transplant evaluation testing and must be billed to the patient’s insurance.  This could entail a financial obligation for the patient, depending on individual circumstances.  But TCN must keep straight initial screening testing (can be coded as such and billed to transplant center) and follow-up testing (which can’t).  TCN needs to be able to participate in periodic audit trails of this documentation.
• Coordinate tracking of test completion, securing and reviewing test results, Coordinate anomaly management & follow-up
• TCN needs tracking system to follow, in near to real time, that a scheduled test was completed (or not), the test was reviewed and resulted, collect the results, review the results for abnormal findings that need prioritized review and disposition by transplant center MD
• TCN needs a clear communication pathway with transplant center MD (or designee) for escalating abnormal results for review and disposition.
• Communication of abnormal results to patients needs to be worked out by prior agreement.  Since this testing is to be ordered by transplant MD and not attending nephrologist MD, a procedure for how abnormal results and recommended follow-up evaluations are communicated to the patient needs to be agreed-to beforehand.  Since the attending nephrologist has a prior relationship with the patient, enlisting them to play a role here may be well advised. 
• TCN will be responsible for Tracking and chasing down missing tests.
• TCN needs clear guidance on how to review patients who repeatedly miss scheduled appointments.
• “Customer relations”
• Potentially, arrange lobby/practice days with transplant center personnel.
• Coordinate joint population level reviews between practices, clinics, and transplant centers.
• Solicit feedback from patients, referring physicians/practices, transplant center on TCN operations.
• Provides continuous updates to Operations Management regarding clinical posture of assigned Centers.
• Performs other related duties as assigned.
  
  
  

PHYSICAL DEMANDS AND WORKING CONDITIONS:

The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• This is a work from home role.
• Day-to-day work includes desk and personal computer work and interaction with patients, facility staff and physicians.
• The position requires travel between assigned Centers. Travel to Organizational Meetings may be required.
  
  
  

SUPERVISION:

• None
  
  
  

EDUCATION AND REQUIRED CREDENTIALS:

• Graduate of an accredited School of Nursing RN BSN required; Advanced degree preferred.
• Current appropriate state licensure
• One multistate license with the ability to practice in all compact states.
  
  
  

EXPERIENCE AND SKILLS:         

• 5 years prior experience in pre-transplant intake and patient education, ICU or similar
• Must have a good understanding of the relationship between providers of healthcare services and regulatory agencies. 
• Must be able to analyze and propose alternative solutions to assist in resolving sensitive to complex issues.
• Experience in quality, risk management, case management, infection control.
• Must have good verbal and written communication skills.
• Excellent interpersonal and communication skills, oral and written.
• Exemplary Customer Service
• Proficiency with the Microsoft office suite (Word, Excel, PowerPoint) - experience with medical database software required.
• Proficiency with EPIC preferred
  
  
  

EO/AA Employer: Minorities/Females/Veterans/Disability/Sexual Orientation/Gender Identity

Fresenius Medical Care North America maintains a drug-free workplace in accordance with applicable federal and state laws.

• Must have ICU and/or critical care nursing experience.
• Kidney transplant experience, highly preferred, but not required.
  
  
  

EOE, disability/veterans