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UPMC is looking for a highly motivated Orthopedic Nurse Navigator/Coordinator to work as part of a multidisciplinary care team to serve our Total Joint Replacement orthopedic patient population. The navigator will provide high quality nursing care, telephonic case management, and care coordination throughout the continuity of care from the pre-operative setting through a patient's entire episode of care. This ONN/Coordinator will implement and modify each patient care plan, as necessary, throughout the transition of care to ensure that the patient achieves quality care outcomes.

Responsibilities:

+ As part of the Total Joint Replacement (TJR) Program the Orthopedic Nurse Navigator/Coordinator is responsible for managing all assigned total joint replacement orthopedic patients throughout their episodes of care, utilizing an intra-collaborative approach.

+ Pre-Operative Period:

+ Develop standardized care plans in conjunction with the appropriate surgeons including pre-op, post-op and discharge orders.

+ Meet with patients one-on-one and communicate the role of the Navigator/Coordinator in the care continuum and the expectations for the patient throughout the episode of care.

+ Identify and track all pre-operative requirements for the patient and ensure they are completed.

+ Establish and maintain relationship-based care with the patient and family.

+ Coordinate the collection of clinical information from the patient record (EMR) and perform telephonic health assessments to determine risk stratification (Including a comprehensive assessment of the physical, emotional, environmental, and psychosocial needs of the patient).

+ Collect and organize all appropriate pre-operative information for all patients including but not limited to (Outpatient PT assessment, pre-op labs, EKG, H&P, Chest X-ray, MRSA nasal swab, and pre-procedure discharge planning).

+ Collaborate with patient's PCP offices and/or hospital pre-op testing centers when necessary to gather important pre-op health information.

+ Schedule and verify patient TJR education class dates.

+ Organize and teach TJR patient education classes when necessary.

+ Coordinate and verify the patient's O.R. reservation.

+ Identify and communicate barriers for the patient for enhanced discharge planning.

+ Peri-Operative Period:

+ Organize and monitor care plans throughout the transitions of care to optimize patient outcomes.

+ Ensure patients receive appropriate educational teaching materials throughout their episode of care and that they are completing all necessary classwork.

+ Coordinate with care providers in the acute, post-acute, and outpatient settings to identify important patient needs (home health, DME, physical therapy, mental health, and various other community services).

+ Reevaluate the plan of care on an ongoing basis based on a patient's health status to determine any necessary changes with other providers involved in the patient's care.

+ Maintain confidentiality of all patient information per HIPAA and UPMC guidelines.

+ Post-Operative Period:

+ Communicate and collaborate with multiple providers and multi-disciplinary care team members to determine discharge destinations for patients post procedure.

+ Follow-up with patients at pre-determined intervals and as needed throughout the episode of care based on patient status, both telephonically and on-site.

+ Coordinate and track physician appointment follow-ups (including patient's PCP, surgeon, and other appropriate providers) at pre-determined intervals for the patient post procedure.

+ Serves as a clinical liaison with outside care providers to include, but not limited to, home health nursing, PT/OT, rehab and SNFs, as well as third party administrators.

+ Willing to learn and utilize Cerner, EpicCare, the O.R. Registration Portal, and other software systems in daily activities to effectively manage TJR patients throughout the continuum of care

+ Maintain flexibility and awareness with changing workloads and patient activity.

+ Learn and understand the various evolving requirements of insurers and regulators in relation to Total Joint Replacement care.

+ Graduate of accredited school of professional nursing.

+ BSN required, Masters preferred.

+ Minimum of 4 years nursing experience in a hospital setting.

+ Telephonic case management experience highly preferred.

+ Experience with the orthopedic specialty highly preferred.

+ Candidates must possess excellent customer service and interpersonal skills.

+ Proficient computer skills and the ability to work independently, multi-task, and problem-solve.

+ Professional oral and written communication skills.

Licensure, Certifications, and Clearances:

+ Act 34

+ Basic Life Support (BLS) OR Cardiopulmonary Resuscitation (CPR)

+ CPR required based on AHA standards that include both a didactic and skills demonstration component within 30 days of hire

+ Registered Nurse (RN)

+ *Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.

UPMC is an Equal Opportunity Employer/Disability/Veteran