Nurse Navigator RN

Job Profile Summary

This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. It also includes Nurse Navigator duties, such as focusing on the patient’s needs, guiding them through the healthcare system, and helping overcome obstacles to obtain necessary care. The position is an individual contributor role that may direct the work of lower level professionals or manage processes and programs.

The majority of the time is spent overseeing the design, implementation, or delivery of processes, programs, and policies using specialized knowledge typically acquired through advanced education. It is a senior-level role that requires advanced knowledge of the job area typically obtained through advanced education and work experience. Typical responsibilities include managing projects and processes, working independently with limited supervision, coaching and reviewing the work of lower level professionals, and resolving difficult and sometimes complex problems.

This position, in conjunction with Case Management, coordinates the transition of care from one health care setting to another, which includes inpatient, home health care, skilled nursing facility, and rehabilitation facilities. It educates the patient and/or family regarding the patient’s clinical condition, treatment, postoperative course, and the patient’s role in recovery. It collaborates and communicates with a wide range of multidisciplinary providers with the goal of achieving an exceptional patient experience and the best possible patient outcomes.

• Associate’s degree in Nursing.
• Registered Nurse (RN) license.
• Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) certification.
• Three (3) years of clinical experience caring for patients with a broad range of complex medical diagnoses.
• Valid state‑issued driver’s license and reliable transportation.

• Bachelor’s degree in Nursing.
• Advanced Practice Registered Nurse (APRN).
• Eligible for state and federal controlled substances registration.
• Five (5) years of clinical experience in home health, post‑acute, or acute settings caring for patients for a broad range of complex medical diagnoses.
• Bilingual.

• Using effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions, promotes improved quality of care, prevents rehospitalization when possible and appropriate, and ensures appropriate transitions of care, including connections with community and acute services.
• Promotes cost‑effective nursing, medical, and functional outcomes.
• Promotes decreased lengths of hospital stays when appropriate with hospital case management transitions of care planning individualized to the patient.
• Assures appropriate levels of care are received by patients and involves family caregivers.
• Improves transitions of care, identifies drivers of avoidable utilization of Emergency Department (ED) use and hospitalization, and diverts unnecessary ED admissions as appropriate.
• Utilizes tele‑monitoring as a key modality in the care and monitoring of high‑risk patients.
• Provides direct patient care/assessment as needed.
• Builds relationships involved in transitions of care planning to steer patients to appropriate post‑acute facility when initial transition to home is not successful (acute vs. subacute rehab, preferred SNF network, etc.).
• Monitors active hospital holds working collaboratively with respective liaison and case manager to ensure best transition of care.
• Partners with hospital and Care Management teams in the build and sustainability of innovative programs within a strong patient‑centered model.
• Provides appropriate consultation and referral to Case Management teams.
• Identifies appropriate alternative and non‑traditional resources and demonstrates creativity in managing each case to fully utilize all available resources to meet medical and social determinants of health.
• Maintains accurate records of all interventions and provides timely verbal and written reports, as directed.
• Prepares regular management…