DEPARTMENT SUMMARY: The Nurse Navigation department engages in a collaborative process between the inpatient and outpatient care teams in conjunction with the patient to address mutual care goals, remove barriers to care, coordinate efforts between multiple care providers and encourages patients to individually manage their care. The work is characterized by advocating for patients to receive the right care, at the right time by the right provider and promotes quality and cost-effective interventions and outcomes.
POSITION OVERVIEW: The RN - Nurse Navigator serves as a single point of contact for referring physicians, patients, and caregivers to provide assistance with accessing clinical and supportive care services offered within St. Charles Health System and the patients’ community. This RN collaborates and coordinates the delivery of quality, efficient and cost-effective health care services for patients inclusive of all providers and partners of the health care team. This position does not directly manage any other caregivers.
ESSENTIAL FUNCTIONS AND DUTIES:
Collaborate with healthcare providers and community partners to develop an evidence-based, comprehensive individualized plan of care. Interventions are patient centered and facilitate effective and efficient medical utilization.
Develops, documents, and monitors patient/family response to plan of care, and revises the plan as indicated. Provides patient self-management support and tools with a focus on empowering the patient/family to build capacity for self-care.
Act as a patient advocate and liaison between patients, providers, specialists, hospital, post-acute care services, and community resources as well as facilitate with internal services and external agencies.
Coordinates care services with other healthcare providers to remove barriers to achieving goals, such as making physician appointments, assuring prescriptions are filled, etc.
Provide follow-up with patient/family when patient transitions from one setting to another. Completes timely follow-up including PCP or specialist follow-up appointments, symptom assessment, providing education utilizing teach back methodology, coordination of care, and problem solving potential and/or actual barriers.
Utilize documentation and evaluation tools to efficiently and accurately document the processes and interactions with patients in the care coordination program.
Participate in multidisciplinary team conferences, and participates in overall program evaluation of processes, identifies problems, and proposes/develops process improvement strategies to enhance care management services.
Acts as a clinic resource to acute care departments and referral agencies to help develop best practice and up to date education.
Represents St. Charles Health System and the navigation program at community events, as applicable to program.
Participates in professional development, regarding evidence-based engagement, communication, behavior change, and care coordination strategies to incorporate into clinical practice that also keeps the health care team current.
Supports the vision, mission and values of the organization in all respects.
Supports Value Improvement Practice (VIP- Lean) principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.
Provides and maintains a safe environment for caregivers, patients and guests.
Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.
Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate.
May perform additional duties of similar complexity within the organization, as required or assigned.
Participates in creating a healing environment that supports all aspects of the care environment and the wholeness of each individual, patient and caregiver.
Participates in creating intentional relationships and demonstrates focus attitudes and behaviors that enhance the care experience.
Provides a therapeutic presence in service to others by purposefully responding to the needs of patients in a caring way, including introducing oneself and explaining role in patient’s care, asking the patient his or her preferred name, sitting with the patient to determine his or her care goals, active listening, and communicating effectively and appropriately through touch, eye contact, etc.
Provides and maintains a safe environment for caregivers, patients and guests
Documents all patient care with proficiency in compliance with hospital policies, procedures and regulatory agencies.
Calculates dosages and administers medications accurately in accordance with St. Charles Health System policies and procedures for medication administration.
Required: As required for RN Licensure
Required: Current Oregon RN license. AHA Basic Life Support for Healthcare Provider certification. Valid Oregon driver’s license and ability to meet SCHS driving requirements. Ability to travel to business functions/meeting with clients and providers/attend trainings/meetings and all SCHS worksites required.
Required: A minimum of 3 years clinic nursing experience related to specialty area. Previous experience with emphasis on disease management and patient education.
Preferred: Experience in case management, nurse navigation, and/or care coordination. Community Health experience.
PERSONAL PROTECTIVE EQUIPMENT
Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.