Facility Navigator - RN

Job ID
Clinical - All


Position Purpose


As part of the primary care patient centered medical home team, the Facility Navigator engages in a collaborative process which assesses, plans, implements, coordinates, and evaluates options and services to meet a member’s health needs through care transitions to promote quality, cost effective outcomes. This process will be applied in various settings to include acute care, skilled nursing care settings and long term acute care settings, rehab facilities, The Facility Navigator functions as part of a multidisciplinary team, which includes a Primary Care Physician, RN Navigator, Care Coordinator-Social Worker, Care Coordinator-Register Nurse, and Nurse Practitioner.


Scope of Position


Responsible for the management of hospitalized members and members treated in the emergency room as part of the patient centered medical home model. Will also have responsibilities to maintain and ensure alignment with mission of Peoples Health as outlined in the mission statement.


Principal Responsibilities


As part of a multi-disciplinary care coordination team:


  1. Reviews all hospitalized members at their assigned facility and determines the appropriate level of interaction.
  2. Reviews all members presenting to the emergency room and provides diagnostic information and medications to the treating physician.
  3. Facilitates follow-up appointments for members presenting to the emergency room who are treated and released.
  4. When indicated by the needs of the member (high risk, readmission, frequent Emergency Department visits, SNP) coordinates on-site reviews to develop a realistic discharge plan that will facilitate continuation of care at the most appropriate level. Review will include quality of care, utilization pattern, and compliance with policy guidelines.
  5. Collaborates with the Primary Care Physician Care Team to identify high risk members that will be followed by the Care Team. This will include Special Needs Plan (SNP) members, members with 30 day readmissions, members in complex case management or needing Complex Case management and members requiring an alternate level of care.
  6. As appropriate, conducts comprehensive assessments of the member’s health and psychosocial needs, including health literacy status and deficits.
  7. Documents transitional assessment (admission and discharge) and follow up concurrent clinical notes in CCMS, outcome and discharge planning activities.
  8. Participates in daily reviews of all members currently in the facility with the respective Care Coordinators and Primary Care Physician Navigators.
  9. Collaborates with the hospital case management staff and facility care providers to review admission and discharge planning issues.
  10. Involves the individual member and care giver, as appropriate, in decision making to assist the member in continuation of care in the outpatient setting.
  11. Applies focus on points of care transitions, which includes a complete transfer to the next care setting provider that is effective, safe, timely and complete.
  12. Interacts with the member and the multidisciplinary team to establish measurable health care goals and prioritization of the member’s needs. Identifies barriers to adherence to the plan of care
  13. Educates the member, and the family or caregiver, about disease states, treatments, plan benefits, community resources, and resource options. Evaluates the member’s readiness and ability to learn.
  14. Develops referrals to appropriate resources to assist member and/or caregiver in continuation of care in an outpatient setting.
  15. If necessary, coordinates with the member and/or caregiver to identify potential barriers to discharge to an alternate level of care.
  16. Communicates discharge information to the care team to facilitate the post hospital discharge visit within seven (7) days.
  17. Encourages the appropriate use of health care resources
  18. Collaborates with care team members and market medical directors to facilitate appropriate treatment of members.
  19. Documents, according to Peoples Health standards of documentation in the Peoples Health CCMS System. Documentation can include discussions/events involving the member or individuals responsible for a member’s welfare.
  20. Participates in meetings with the PCP for review of the census as indicated
  21. Census update daily to include assignment of member to Care Coordinators.
  22. Promotes a professional positive image of Peoples Health throughout the community. Identifies and communicates community concerns and problems affecting Peoples Health to appropriate departments.
  23. Answers pages and phone calls received from hospital utilization review regarding a patient’s condition during business hours.
  24. Completes Service Forms in accordance with department policy including time-lines and Standards of Documentation.
  25. Promote quality outcomes and participates in the measurement and understanding of those outcomes
  26. Pursues professional excellence and maintains competence in practice through ongoing learning and education.



Core Competencies

  •  Professionalism
  • Strong verbal and written communication skills
  • Planning and organizational skills
  • Creative/innovative thinking
  • Negotiator
  • Conflict management and resolution
  • Manages time appropriately/efficiently/effectively
  • Strategic thinker
  • Problem solving and decision making
  • Effective listener
  • Collaboration and team work
  • Excellence with interpersonal relations
  • Ability to work independently and pro-actively, and make decisions.
  • Ability to handle multiple demands of diverse workload and prioritizes critical issues.
  • Ability to effectively interact with multifaceted medical professional staff.
  • Pleasant and helpful attitude.



  • Diploma or degree in nursing; BSN highly preferred
  • License to practice as a RN issued by the Louisiana State Board of Nursing
  • Minimum of 3 years nursing experience in clinical or similar setting required.
  • Experience utilizing an EMR system also required.
  • Experience in managed care industry preferred.
  • Understanding of HMO and third party administration preferred.
  • Understanding of Nursing Home and Long Term Acute Care regulations preferred.
  • Continuing education in the health-care/managed care industry preferred.
  • Ability to operate standard office equipment, computer, printer, fax and copier.


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