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As a MDS Nurse, you will coordinate and facilitate the timely and accurate completion of the RAI and Care Management process from admission to discharge You will coordinate and manage the daily care management meeting, maintain the tracking system of MDS schedules, and coordinate care plan conferences with residents, families and interdisciplinary team 
$76,689 - $103,521 / year
As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive. Job Location (Full Address): 601 Elmwood Ave, Rochester, New York, United States of America, 14642 Opening: Worker Subtype: Regular Time Type: Full time Scheduled Weekly Hours: 40 Department: 500177 Surgery Quality Assurance Work Shift: UR - Day (United States of America) Range: UR URCE 214 Compensation Range: $76,689.00 - $103,521.00 The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job's compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations. Responsibilities: The nurse navigator is a specialized hospital-based registered nurse who ensures that complex geriatric patients receive customized, age-friendly care preoperatively, during their in-hospital recovery, and undergo safe, highly coordinated transitions out of the hospital. They act as the central hub of communication between the various inpatient and outpatient teams to ensure various components of the Geriatric Surgery Verification (GSV) program are completed, supporting high-value, streamlined surgical care provided to older adult patients (typically 65+). This role collaborates closely with surgical teams, Centers for Perioperative Medicine (CPM), hospitalists, specialists (other consulting teams, PT/OT, nutrition), nursing staff (emergency department, ICU, surgical units), and social workers. Provides individualized assistance, support and comprehensive coordination of care of geriatric surgical patients and their families/caregivers through the full surgical journey from pre-operative preparation and screening, the perioperative period, discharge, and post-operative follow-up. Navigator will ensure components of the GSV program are met, complete assessments to risk stratify patients to determine clinical needs, work to eliminate barriers to timely care, facilitate interactions with care teams, increase patient and provider satisfaction, maintain point of contact with providers and serve as a point of contact for patients and families. ESSENTIAL FUNCTIONS Assists with preoperative phone screens to ensure elective surgery patients are screened for frailty. Ensures frail preoperative patients get timely referral and appointments for preoperative evaluations at the Centers for Perioperative Medicine. Ensures appropriate communication to inpatient co-management team, surgical team and primary care physician. Identifies high-risk geriatric patients upon admission or in the Emergency Department. Completes baseline assessments of patients including cognition, delirium risk, functional status including risks for falls, and polypharmacy. Develops relationships with patients, families, and caregivers from time of diagnosis through initiation and completion of active treatment. Maintains collaborative relationships with families/caregivers, multidisciplinary provider(s), nursing leadership and staff, and other internal service delivery departments. Facilitates communication among members of the multidisciplinary team. Supports care team handoffs for a smooth transition through each care setting. Serves as ongoing resource for patients and families during treatment and post discharge. Identifies patient needs and collaborates with other care providers regarding how to best meet the needs and sequence care. Participates in implementation and evaluation of age-friendly policies and procedures. This includes current standards and any new standards to keep us in compliance with the program. Based on compliance data this may also involve assessment of practice patterns and barriers to compliance, developing and implementing action plans to improve. Provides community education on age-friendly efforts and engages the community on issues in age-friendly care such as advanced directives, shared decision making, and maintaining function. Develops and participates in patient, family, and staff teaching. Develops and updates appropriate written patient education materials. Participates in high-risk conference, organizes meeting and patient rooster, and disseminates meeting minutes and feedback to participants and teams. Other duties as assigned. MINIMUM EDUCATION & EXPERIENCE Bachelor's degree in Nursing (BSN) and 3 years of clinical Nursing experience required with at least 1-2 years in acute care setting (e.g. Med-Surg, ICU, or ED) strongly preferred. Or equivalent combination of education and experience Previous nurse navigator, care coordination, case management or utilization with a strong background in geriatrics, home health, palliative care a plus If candidate is currently an Associates Degree RN, nurse has 5 years to complete BSN KNOWLEDGE, SKILLS AND ABILITIES Competence in critical thinking, interpersonal relationships and technical skills required An understanding of geriatric syndromes, chronic disease processes, and polypharmacy management strongly preferred. Exceptional communication and active listening skills, with the ability to communicate empathetically with older adults and stressed family caregivers strongly preferred. Exceptional communication and active listening skills with the ability to communicate with interdisciplinary specialties and professionals strongly preferred Proactive, self-directed and motivated with strong organizational skills and the ability to work autonomously in a fast-paced environment strongly preferred. Proficiency with Electronic Health Records (EHR) systems and documentation and Microsoft Office strongly preferred. Has contributed to quality improvement, performance excellence, or unit performance (UPP) initiatives strongly preferred Has contributed to the identification and development of goals and workflows aimed at improving outcomes for patients and families strongly preferred LICENSES AND CERTIFICATIONS RN - Registered Nurse - State Licensure and/or Compact State Licensure upon hire required Certified Case Manager (CCM), Board Certification in Gerontological Nursing (RN-BC), or equivalent navigation certification is encouraged Certification in Nursing specialty area upon hire preferred The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University’s Mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law. 
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