Novant Health UVA Health System Culpeper Medical Center
Culpeper, VA 22701, USA
The Nurse Navigator works with a multidisciplinary team to plan and coordinate the delivery of care for a disease specific patient population (breast care) across the Medical Center. The Navigator provides education and support to patients and their families, facilitates transitions of care to assure that patients have appropriate referrals and follow-up appointments post discharge, and works with the multidisciplinary team to implement and sustain evidence based practice. The main objectives of this role are to facilitate patient self-management, prevent readmissions, increase patient satisfaction and ensure that patients receive necessary services. The Navigator will work closely with other disciplines to achieve quality patient care.
Some of the major job functions include but are not limited to:
Collaborates with care management to evaluate and follow patients for potential needs, medication assistance and community resources.
Plans individualized care in collaboration with the multidisciplinary team.
Gathers information necessary to guide the development of the self-management plan for the patient. This information may include psychological assessment, literacy level, social assessment and economic barriers.
Identifies and coordinates the care of disease specific population specific inpatients and outpatients to include
Monitoring adherence to disease specific guidelines
Collaborating with attending physician/ residents/ nurse practitioners and/or primary care physician and other practitioners relevant to the patient’s care across the inpatient and outpatient care settings
Monitoring resource utilization
Documenting coordination of care in the medical record.
Provides, reinforces, and documents patient and/or caregiver disease specific and health maintenance education.
Identifies potential barriers to effective disease management and/or etiology for readmissions. Works with established multidisciplinary teams to develop appropriate interventions to address barriers.
Implements a plan to address short and long term care needs.
Manages and coordinates care to include:
Collaborate with multi-disciplinary team to ensure all educational needs and patient needs are identified and arranged
Verify patient has appropriate community resources for effective self-management (i.e. pharmacy access, transportation, etc)
Arranging and/or verifying appropriate follow-up appointments have been made within one week of discharge or clinic visit. Explains to patient the purpose and importance of attending these appointments.
Performs phone calls to assure patient has appropriate medications, understands discharge instructions, and answer questions.
Facilitates transition of care: Screens and facilitates referral to appropriate multi-disciplinary team members (i.e. palliative care, physical therapy, occupational therapy, etc). Communicates with other providers, including primary care physician offices, home health agencies, skilled nursing facilities, and other external programs to promote continuity of care. Provides appropriate orderset/management plan and “hand-off’ communication
Ensure appropriate multi-disciplinary team members have counseled patient
Assists with evaluation of patient care outcomes.
Graduation from accredited school of Nursing
Bachelors in Nursing or in process of obtaining preferred
1 year of relevant experience
Five years clinical experience with knowledge in the care of disease specific population preferred
Knowledge, skills and abilities required:
Demonstrates effective communication skills to provide patient education.
Demonstrates effective communication skills to discuss case management, financial, clinical issues with hospital based case managers, physicians, outside agencies and facilities, nurses, and other healthcare professionals in the community.
Autonomous, self-starter with the ability to make independent decisions.
Organized with effective time management skills.
Detail oriented with ability to facilitate change and affect positive results
Proficient in computer/web-based tools.
Registered Nurse with a current licensure in the Commonwealth of Virginia
Certified in Healthcare Provider BLS
Certified in ACLS & PALS preferred
Certified in Specialized area preferred
National specialty certification required, or obtained within 2 years.