Nurse Navigator (Discharge Planner)

The Nurse Navigator (Discharge Planner) plays a key role in ensuring a safe and smooth transition from hospital to home. Focusing on discharge readiness, the Nurse Navigator coordinates care, arranges services, and educates patients and families to support recovery at home and reduce readmission risk. Using the care transition model, this role empowers patients through guidance, advocacy, and improved communication with healthcare providers—helping them manage their health confidently after discharge

*** Salary Range $32 - $34/hr ***

#INDNURSING

Salary Disclosure Statement

The salary mentioned above reflects the potential base pay range for this role. Bonuses or other incentives (if applicable) are offered separately. Offers will consider such factors as overall experience, job-related qualifications, location, certifications/training, etc.

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Responsibilities

• Meets with patients and families upon admission to better understand patients’ prior level of function and to discuss initial discharge plan.
• Attend PDPM meeting and engage with interdisciplinary team regarding patient discharges.
• Order durable medical equipment prior to discharge.
• Assess patients who require oxygen upon discharge and order oxygen as needed.
• Arrange for overnight oximetry tests for patients requiring PAP machines upon discharge. Order PAP machine as indicated.
• Attend care plan meetings as needed.
• Place follow up discharge phone call to patient/responsible party within 72 hours of discharge to ensure all necessary services are in place.
• Complete discharge paperwork and place in patient chart.
• Formulate discharge email and update as needed to keep all interdisciplinary team members informed.
• Complete Health Care Practitioner Form/Resident Assessment Tool for all patients discharging to an assisted living.
• Coordinator smooth transition with all Assisted Living Facility personnel.
• Gather referral packet and communicate with other SNF’s for patients transitioning to other long term care settings.
• Complete and obtain signature from physician for Face to Face.
• Arrange for home health services.
• Assist family is obtaining transportation for community dialysis as needed.
• Arrange for transition to community dialysis for dialysis patients.
• Connect with patients and families one week prior to discharge to assess for discharge needs.
• Assist patient and family with locating community resources as needed.
• Work collaboratively with local hospitals, to include attending meetings, as it pertains to facility admissions and discharges.
• Abide by the standards identified in FutureCare’s Statement of Corporate Ethics and the Corporate Compliance Plan.

Requirements

• Must hold an active LPN license issued in the state of Maryland.
• Preferred experience in a skilled nursing, sub-acute, or health care setting.
• Excellent interpersonal skills to appropriately relate to patients, their families, other staff members, department heads and community agency personnel.
• Demonstrated oral and written communication skills.
• The ability to discreetly manage confidential information.
• The ability to function as a member of an interdisciplinary team.
• The capacity to handle a large volume of admissions and discharges.

Equal Opportunity Employer 

FutureCare has a longstanding policy of providing a work environment that respects the dignity and worth of each individual and is free from all forms of employment discrimination, including harassment, because of race, color, sex, gender, pregnancy, age, religion, national origin, citizenship, marital status, sexual orientation, gender identity, gender expression, physical or mental disability, military or veteran status, or any other characteristic protected by law. We actively promote equality of opportunity for all and welcome all applications.