Work where every moment mattersEvery day almost Hartford HealthCare employees come to work with one thing in common Pride in what we do knowing every moment matters here We invite you to become part of Connecticutrsquos most comprehensive healthcare networkHartford Hospital is one of the largest and most respected teaching hospitals New England We are a Level Trauma Center that provides cutting edge treatment to its patients This is made possible by being home to the largest robotic surgery center in the Northeast and the Center for Education Simulation and Innovation CESI one of the most advanced medical simulation training centers in the world When hospitals cannot provide the advanced care expertise and new treatment options their patients require they turn to usThe Community Care Center CCC is located at Retreat St on the third floor of the Brownstone building of Hartford Hospital CCC clinic has close to patient visits annually with an average of patients per day The Division of Infectious Diseases provides inpatient and outpatient consultation regarding the diagnosis and management of all types of infectious diseases The service is supported by outstanding clinical diagnostics laboratories which provide state of the art techniques for rapid diagnosis of infectious diseases Our staff of providers Psychiatry fellows Psych Residents social worker Nutritionist Pharmacy Liaison APRNs RNs MAMAAs a Case Manager and a Data Manager who provides compassionate care excellence in teaching and investigations in clinical and laboratory research CCC is Ryan White funded are bilingual with Spanish being their primary language of our patients have Health coverage under Medicaid Our specialists are skilled at treating many infectious condition including Conditions such as HIV infection Hepatitis fever of unknown origin recurrent infections or rashes of unknown type or origin Influenza Opportunistic infections in patients who are immunosuppressed due to acquired or congenital immunodeficiency transplant or other medical condition CCC guides patients through the health system including appropriate referrals for services to other health professionalsJob SummaryFunctioning within the context of the framework for professional nursing practice the Community Care Nurse Navigator is a registered nurse experienced in patient throughput preventing transitional care gaps and resolving issues to enhance the quality and continuity of a patientrsquos or populations health care leading to improved health outcomes and equitable care This role supports the HHC mission to improve the health and healing of the people and communities we serve Job Responsibilitiesbull Functions as a member of an interprofessional care team in an expanded nurse role to help those patients without a primary care provider transition from the acute care setting HH ED or inpatient The goals include reducing all cause readmissions and inappropriate ED utilization improving care coordination for patients during the transitional care period and ultimately improving care quality and access for vulnerable populations This role will be responsible for educating the HH community at large and advocating for resources to enhance patient healthcare engagement and expand the collaboration and communication between inpatientambulatoryoutpatientattendingtransitional carespecialty careprimary care providers and care teams for high riskcomplex patientsbull Partners with the inpatient ie acute care IOL STR or ED physician and care team to proactively identify potential transitional care gaps for this patient population and establish a safe transition plan Key strategies include ensuring a patientcaregiver agreed upon Center for Transitional CareTransition Clinic and urgent specialists scheduled appointments with transportation verifying patient has necessary DME finalizing an achievable community medication plan completing diagnostic workup educating the patient on disease and symptom management and incorporating a patient centered home care planbull Performs post hospitalizationED transitional care strategies within h after discharge including post discharge phone calls patient education symptom management and medication reconciliation and collaborates with transition clinic physician and clinic and community care team to minimize identified gaps in carebull Throughout the post inpatientED transitional care period facilitates the completion of the diagnostic workup follows up on unresulted diagnostics collaborates with homecare pharmacy and DME to ensure the patient has necessary suppliesmedicationsresources obtains necessary authorizations and schedules additional consultant appointmentsbull Collaborates with clinic physicians to resolve issues and to advance the treatment plan until the patient has an established primary care providerbull In collaboration with the Transition Clinic physician assists the patient in identifying a primary care practice for continued care and facilitates the transfer of care to that practicebull Documents all communication transition plan implemented strategies and patient outcomes in EPICbull As a member of the Center for Transitional CareTransition Clinic completes transitional care strategies and actions per CMSPayer guidelines for Transitional Care Management or other program directivesbull Establishes a therapeutic rapport with patients and demonstrates a commitment to serve as a patient advocate bull Demonstrates the ability to work independently as well as collaboratively as a member of the health care team in order to provide safe patient care and prompt and efficient service The Transitional Care Nurse Navigator provides transitional care strategies to hisher peerscolleagues and patients based on needcoveragebull AttendsLeads and actively participates in care team meetings to facilitate a safe transition plan or resolve a patient issuebull Establishes evidence based standard work and workflows Develops and implements processes that improve the patient experience Collects and analyzes patient and program level data identifies areas of opportunity recommends improvementsrevisions or program development and leadsparticipates in the ideaplan implementationbull Applies the nursing process as appropriate within the context of the organizationrsquos framework for professional nursing practice and following guidelines established by the teamWork where every moment mattersEvery day almost Hartford HealthCare employees come to work with one thing in common Pride in what we do knowing every moment matters here We invite you to become part of Connecticutrsquos most comprehensive healthcare networkHartford Hospital is one of the largest and most respected teaching hospitals New England We are a Level Trauma Center that provides cutting edge treatment to its patients This is made possible by being home to the largest robotic surgery center in the Northeast and the Center for Education Simulation and Innovation CESI one of the most advanced medical simulation training centers in the world When hospitals cannot provide the advanced care expertise and new treatment options their patients require they turn to usThe Community Care Center CCC is located at Retreat St on the third floor of the Brownstone building of Hartford Hospital CCC clinic has close to patient visits annually with an average of patients per day The Division of Infectious Diseases provides inpatient and outpatient consultation regarding the diagnosis and management of all types of infectious diseases The service is supported by outstanding clinical diagnostics laboratories which provide state of the art techniques for rapid diagnosis of infectious diseases Our staff of providers Psychiatry fellows Psych Residents social worker Nutritionist Pharmacy Liaison APRNs RNs MAMAAs a Case Manager and a Data Manager who provides compassionate care excellence in teaching and investigations in clinical and laboratory research CCC is Ryan White funded are bilingual with Spanish being their primary language of our patients have Health coverage under Medicaid Our specialists are skilled at treating many infectious condition including Conditions such as HIV infection Hepatitis fever of unknown origin recurrent infections or rashes of unknown type or origin Influenza Opportunistic infections in patients who are immunosuppressed due to acquired or congenital immunodeficiency transplant or other medical condition CCC guides patients through the health system including appropriate referrals for services to other health professionalsJob SummaryFunctioning within the context of the framework for professional nursing practice the Community Care Nurse Navigator is a registered nurse experienced in patient throughput preventing transitional care gaps and resolving issues to enhance the quality and continuity of a patientrsquos or populations health care leading to improved health outcomes and equitable care This role supports the HHC mission to improve the health and healing of the people and communities we serve Job Responsibilitiesbull Functions as a member of an interprofessional care team in an expanded nurse role to help those patients without a primary care provider transition from the acute care setting HH ED or inpatient The goals include reducing all cause readmissions and inappropriate ED utilization improving care coordination for patients during the transitional care period and ultimately improving care quality and access for vulnerable populations This role will be responsible for educating the HH community at large and advocating for resources to enhance patient healthcare engagement and expand the collaboration and communication between inpatientambulatoryoutpatientattendingtransitional carespecialty careprimary care providers and care teams for high riskcomplex patientsbull Partners with the inpatient ie acute care IOL STR or ED physician and care team to proactively identify potential transitional care gaps for this patient population and establish a safe transition plan Key strategies include ensuring a patientcaregiver agreed upon Center for Transitional CareTransition Clinic and urgent specialists scheduled appointments with transportation verifying patient has necessary DME finalizing an achievable community medication plan completing diagnostic workup educating the patient on disease and symptom management and incorporating a patient centered home care planbull Performs post hospitalizationED transitional care strategies within h after discharge including post discharge phone calls patient education symptom management and medication reconciliation and collaborates with transition clinic physician and clinic and community care team to minimize identified gaps in carebull Throughout the post inpatientED transitional care period facilitates the completion of the diagnostic workup follows up on unresulted diagnostics collaborates with homecare pharmacy and DME to ensure the patient has necessary suppliesmedicationsresources obtains necessary authorizations and schedules additional consultant appointmentsbull Collaborates with clinic physicians to resolve issues and to advance the treatment plan until the patient has an established primary care providerbull In collaboration with the Transition Clinic physician assists the patient in identifying a primary care practice for continued care and facilitates the transfer of care to that practicebull Documents all communication transition plan implemented strategies and patient outcomes in EPICbull As a member of the Center for Transitional CareTransition Clinic completes transitional care strategies and actions per CMSPayer guidelines for Transitional Care Management or other program directivesbull Establishes a therapeutic rapport with patients and demonstrates a commitment to serve as a patient advocate bull Demonstrates the ability to work independently as well as collaboratively as a member of the health care team in order to provide safe patient care and prompt and efficient service The Transitional Care Nurse Navigator provides transitional care strategies to hisher peerscolleagues and patients based on needcoveragebull AttendsLeads and actively participates in care team meetings to facilitate a safe transition plan or resolve a patient issuebull Establishes evidence based standard work and workflows Develops and implements processes that improve the patient experience Collects and analyzes patient and program level data identifies areas of opportunity recommends improvementsrevisions or program development and leadsparticipates in the ideaplan implementationbull Applies the nursing process as appropriate within the context of the organizationrsquos framework for professional nursing practice and following guidelines established by the teambull Bachelorrsquos Degree required MSN preferredbull Minimum five years of nursing experience Inpatient and Ambulatory nursing experience preferredbull Current Connecticut Nursing Licensebull BLS Certificationbull Obtain CCMCCCTM certification within two years of hireWe take great care of careersWith locations around the state Hartford HealthCare offers exciting opportunities for career development and growth Here you are part of an organization on the cutting edge ndash helping to bring new technologies breakthrough treatments and community education to countless men women and children We know that a thriving organization starts with thriving employees we provide a competitive benefits program designed to ensure worklife balance Every moment matters And this is your momentAs an Equal Opportunity EmployerAffirmative Action employer the organization will not discriminate in its employment practices due to an applicantrsquos race color religion sex sexual orientation gender identity national origin and veteran or disability statusbull Bachelorrsquos Degree required MSN preferredbull Minimum five years of nursing experience Inpatient and Ambulatory nursing experience preferredbull Current Connecticut Nursing Licensebull BLS Certificationbull Obtain CCMCCCTM certification within two years of hireWe take great care of careersWith locations around the state Hartford HealthCare offers exciting opportunities for career development and growth Here you are part of an organization on the cutting edge ndash helping to bring new technologies breakthrough treatments and community education to countless men women and children We know that a thriving organization starts with thriving employees we provide a competitive benefits program designed to ensure worklife balance Every moment matters And this is your momentAs an Equal Opportunity EmployerAffirmative Action employer the organization will not discriminate in its employment practices due to an applicantrsquos race color religion sex sexual orientation gender identity national origin and veteran or disability status