Clinical RN Navigator – Multi-Specialty Clinic

The Nurse Navigator is responsible for supporting the navigation of patients through complex healthcare environments for the optimization of care and outcomes. This position functions autonomously and in collaboration with other members of the healthcare team. The Nurse Navigator is an integral member of the care team guiding patients through the health care system by assisting with access issues, addressing barriers to care, scheduling outpatient and surgical procedures, and tracking interventions and outcomes.

The Nurse Navigator serves as a resource person for staff and models a commitment to the organization’s vision/mission/values to support an unparalleled patient experience and positive clinical outcomes.

This position is considered Hybrid, which means that individuals in this position may work both at an approved offsite location and Onsite at a primary location or multiple locations based on Business Needs.

Essential Duties

• Collaborates with the patient’s care team including, primary care team, specialists, home care, hospital team, and any others involved with the patient’s care to optimize clinical outcomes.
• Reviews clinical progress of patients and coordinates communications to referring, consulting, and primary care physicians.
• Coordinates scheduling of appointments, outpatient diagnostics and surgical procedures.
• Assists with tracking outcomes of referrals and treatments.
• Communicate with PCP and other team members to ensure continuity of care, both within the Central Health enterprise and external to the health center.
• Participates in daily patient care (unit) huddles, in some case ensuring that huddles are taking place along with weekly clinic staff informational huddles.
• Serves as an advocate, providing direction and support to the patient and family. Educates patient and family members on diagnosis, treatments, procedures, and medications.
• Enhances the patient experience by practicing AIDET during each patient interaction.
• Utilizes Motivational Interviewing or other behavior change techniques to coach and assist the patient with self-management.
• Conducts transitions of care activities with the patient’s medical home care management team or the Central Health case management team as indicated to support patients with complex health, social determinants of health (SDOH) and behavioral health needs, or frequent hospital utilization.
• Enhances the patient experience by supporting Provider teams with in-basket management, refilling medications, and triaging patients in a timely manner following established protocols.
• Assists in the development of departmental protocols, policies, and procedures.
• Participates in continuous quality improvement projects in order to better serve the patient, family and healthcare system to improve the quality of service provided.
• In collaboration with the Nurse Manager, maintains awareness of key performance indicators/metrics and coordinating interventions to prevent avoidable ER visits, hospital admissions and readmissions, etc.
• Attends staff meetings and education offerings both in person and via teleconference/online as required.
• Supports organizational initiatives to promote and maintain a strong positive workplace culture.
• Performs other duties as assigned.

Knowledge/Skills/Abilities: High level of skill at building relationships and providing excellent customer and patient care. High degree of knowledge and competency in the practice of nursing and documentation requirements. Ability to facilitate patient access across the healthcare continuum. High level of problem-solving skills to better serve patients and staff Excellent verbal and written communication skills required. Ability to work collaboratively with both internal and…