Nurse Care Navigator

PURPOSE AND SCOPE:

Responsible for coordination and management of evaluation of kidney transplant patients in the pretransplant

phase. TECN will work in collaboration with their TECN Scheduler to schedule, confirm and execute testing. TECN will review results of testing (see responsibilities) and compile all testing once complete to submit to transplant center. TECN will review all testing and elevate abnormal testing to designated Transplant Center physician. TECN will also collaborate with the Transplant Center team to accomplish pre transplant evaluation where appropriate. TECN will attend meetings with Transplant Center when needed and present patients at selection conference for decisioning on

candidacy.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Clinical review of Incoming Referrals & Start Referral Testing per Protocol

o Team meetings with transplant center clinician leaders to confirm permission to order testing prior to being seen 1:1 by clinician.

• Confirm Pre-Evaluation Work-Up Tests Requested by Transplant Center

o Includes securing “signature” from transplant center MD on orders for testing.

o Contact patient and secure “consent for transplant evaluation” (needed to bill the

transplant center for testing and services)

o Work out with transplant center: Should patient/family education session by

transplant center about risks/benefits of transplantation and orientation to the

evaluation process happen prior to securing consent to referral.

• Order missing health screening tests (Txp Neph signature)

o These are orders for testing that is not on the “standard list” of UNOS-required labs

and/or not explicitly outlined in transplant center evaluation testing guidelines.

• Schedule health screening tests (hospital services/external partners)

o Need to identify local partners (e.g. local radiology centers, local cardiology clinics)

who can undertake necessary testing:

o Ostensibly, CXR, mammogram, CT abd/pelvis to assess vasculature can all be done

in same place at the same time.

o ECG, transthoracic echo, and/or stress echo, and/or biochemical-provoked stress

test can all be done in same cardiology testing center at the same time.

o Pap smear – q 3 years by current screening requirements.

o Colonoscopy versus Cologuard is a point of discussion with transplant center clinical

leadership. Assist patient in scheduling if necessary.

o Dental – Assist patients in obtaining dental Need to work out specific dentist

resources particularly for traditional Medicare or dual-eligible patients.

o There may be “special case” scenarios for patients with specific insurance. E.g.

some commercially insured patients may require testing to be done at the

transplant center parent hospital. Need to develop a clear algorithm with

communication pathway with transplant center administrator/billing personnel to

address questions.

• Review all results and review abnormal testing with designated Transplant Center physician

or designee.

• Organize To/From Transport for Patient

o Ideally, location of radiology and/or cardiology clinic is less important if this is “one

off” testing, that is, all testing can be done same place/same day x 1.

o Consider “special transportation” for selected patients. Preference is that much of

this transportation can either be via patient themselves, patient-caregiver/friend,

and if otherwise not available, via non-critical transportation (e.g. Uber/Lyft).

o Distinguish between tests that require a “support person” after (e.g. colonoscopy and anesthesia).

• Confirm patient intent/attendance (dialysis clinic SW)

o TECN will periodically need to communicate/coordinate with FKC clinic MSW about

upcoming appointments.

o TECN will need to communicate with FKC MSW about patients that are proving to be

difficult/impossible to schedule/re-schedule – Approach for escalation to

attending nephrologist to review if patient really is a candidate for referral or

whether there is a psychosocial barrier that has been uncovered.

• Coordinate billing & reimbursement for testing with transplant center Financial Coordinator

o Familiarization with key billing codes for testing to ensure this is billed through the

transplant center and not billed to the patient.

o Key part of patient consent: Any follow-up testing because of an abnormal test is not

part of the transplant evaluation testing and must be billed to the patient’s

insurance. This could entail a financial obligation for the patient, depending on

individual circumstances. But TECN must keep straight initial screening testing

(can be coded as such and billed to transplant center) and follow-up testing (which

can’t). TECN needs to be able to participate in periodic audit trails of this

documentation.

• Coordinate tracking of test completion, securing and reviewing test results, attach results to

original referral from FKC clinic as “single package,” deliver and confirm receipt of records by

Transplant Center. Coordinate anomaly management & follow-up

o TECN needs tracking system to follow, in near to real time, that a scheduled test was

completed (or not), the test was reviewed and resulted, collect the results, review

the results for abnormal findings that need prioritized review and disposition by

transplant center MD, include all the testing results into a comprehensive “referralplus”

packet, and deliver with confirmed receipt to transplant center.

o TECN needs a clear communication pathway with transplant center MD (or

designee) for escalating abnormal results for review and disposition.

o Communication of abnormal results to patients needs to be worked out by prior

agreement. Since this testing is to be ordered by transplant MD and not attending

nephrologist MD, a procedure for how abnormal results and recommended followup

evaluations are communicated to the patient needs to be agreed-to

beforehand. Since the attending nephrologist has a prior relationship with the

patient, enlisting them to play a role here may be well advised.

• Tracking and chasing down missing tests.

o TECN needs password-protected access to Spectra results platform as well as to

radiology and cardiology testing partners. Access needs to include visibility into

confirming test was ordered, confirming test was completed, and results review.

o Transplant centers will likely want access to actual films. Rather than make TECN

responsible for this, it would be preferable to have a routine means of delivering

actual films to transplant center for uploading into system. API for transplantrelated

labs between Spectra and transplant center, tagged to ordering MD inbox

for review, would be preferred.

o TECN needs clear guidance for how to review patients who repeatedly miss

scheduled appointments.

• “Customer relations”

o Arrange lobby/practice days with transplant center personnel.

o Coordinate joint population level reviews between practices, clinics, and transplant

centers.

o Solicit feedback from patients, referring physicians/practices, transplant center on

TECN operations.

• Provides continuous updates to Operations Management regarding clinical posture of

assigned Centers.

• Performs other related duties as assigned.

PHYSICAL DEMANDS AND WORKING CONDITIONS:

The physical demands and work environment characteristics described here are representative of

those an employee encounters while performing the essential functions of this job. Reasonable

accommodations may be made to enable individuals with disabilities to perform the essential

functions.

• Day to day work includes desk and personal computer work and interaction with patients,

facility staff and physicians.

• The work environment is characteristic of a health care facility with air temperature control

and moderate noise levels.

• May be exposed to infectious and contagious diseases/materials.

• The position requires travel between assigned Centers. Travel to Organizational Meetings

may be required.

SUPERVISION:

• None

EDUCATION AND REQUIRED CREDENTIALS:

• Graduate of an accredited School of Nursing RN BSN required; Advanced degree preferred.

• Current appropriate state licensure

• One multistate license with the ability to practice in all compact states.

EXPERIENCE AND SKILLS:

• 5 years prior experience in pre-transplant intake and patient education, ICU or similar

• Must have a good understanding of the relationship between providers of healthcare

services and regulatory agencies.

• Must be able to analyze and propose alternative solutions to assist in resolving sensitive to

complex issues.

• Experience in quality, risk management, case management, infection control.

• Must have good verbal and written communication skills.

• Excellent interpersonal and communication skills, oral and written.

• Exemplary Customer Service

• Proficiency with the Microsoft office suite (Word, Excel, PowerPoint) - experience with

medical database software required.