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Posted: 13-Feb-25
Location: Bend, Oregon
Categories:
Internal Number: R1019208
Ambulatory Nursing Administration - RN Failure Nurse Navigator
Remote/Hybrid - Bend
ST. CHARLES HEALTH SYSTEM
JOB DESCRIPTION
TITLE: Nurse Navigator
REPORTS TO POSITION: Manager, Nurse Navigation
DEPARTMENT: Ambulatory Nursing Leadership
DATE LAST REVIEWED:March 2024
OUR VISION: Creating Americas healthiest community, together.
OUR MISSION: In the spirit of love and compassion, better health, better care, better value
OUR VALUES: Accountability, Caring and Teamwork
DEPARTMENT SUMMARY: The St. Charles Nurse Navigation and Care Transition team focuses on patient-centered transitions, which provides a seamless delivery of quality care from inpatient to the outpatient care team. The Ambulatory Care Nurse Navigation team collaborates with a multidisciplinary group to respond to the patients needs during transitions of care.
POSITION OVERVIEW: The Nurse Navigator in Ambulatory Care coordinates efforts to improve patient outcomes through the assessment and advocacy of patient needs. The Nurse Navigator provides evidence-based disease specific education, develops care plan goals and interventions, monitors and responds to barriers, and connects the patient to needed resources. This position does not directly manage any other caregivers.
ESSENTIAL FUNCTIONS AND DUTIES:
Responsible for the collaboration with multidisciplinary teams to provide seamless patient care when transitioning from inpatient to the outpatient setting.
Coordinates patient follow-up with Primary Care Provider (PCP) in a timely manner as evident by predefined performance measures.
Assess patient need through intake, care gap identification, screening for social determinants of health (SDOH) and providing triage if needed.
Creates a plan of care and interventions with the patient to meet their health goals. Acts as a guide for the patient as they are learning how to manage their illness.
Provides standard evidence-based nursing education for specific disease management.
Monitors patient specific outcomes, provides follow-up and adjusts the plan if needed.
Assists patients to access services, advocates to remove barriers and connects patients and families to resources internally and in the community.
Maintains knowledge of department specific metrics and strives to meet those goals.
Cultivates effective partnerships and works collaboratively with all members of the care team, including the patient and family.
Functions as an active liaison between the clinics, hospital and other care settings and agencies throughout the community.
May perform data entry and data analysis pertinent to specific programs or accreditation measures. Specific roles may be involved with national programs and data collection including, but not limited to the following: American Heart Association: Get with the Guidelines, Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), and the Metabolic and Bariatric Surgical Reviewer (MBSCR) role as defined by the American College of Surgeons.
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 patients 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.
Develops cultural competence and provides appropriate care to patients and family members who belong to diverse cultural backgrounds.
Supports the vision, mission, and values of the organization in all respects.
Supports the 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 organizations 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.
EDUCATION:
Required: As required for RN licensure.
Preferred: Bachelors degree in nursing.
LICENSURE/CERTIFICATION/REGISTRATION:
Required: Oregon RN license, BLS/CPR. Ability to travel to SCHS worksites if/when needed.
Preferred: N/A
EXPERIENCE:
Required: Three (3) years nursing experience. Previous experience with emphasis on disease management and patient education.
Preferred: Community health setting with knowledge of caring for chronic conditions required; previous experience in Care Coordination or Case Management.
PERSONAL PROTECTIVE EQUIPMENT:
Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.
ADDITIONAL POSITION INFORMATION:
SKILLS:
Excellent organizational, written, and oral communication and customer service skills.
Strong analytical, problem solving and decision-making skills. Ability to make independent nursing judgments, problem solves and prioritizes workload.
Basic to intermediate ability and experience in computer applications, specifically electronic medical records system, and MS Office. Demonstrates ability to maintain accurate notes and records.
PHYSICAL REQUIREMENTS:
Continually (75% or more): Standing and walking, keyboard operation, use of clear and audible speaking voice and the ability to hear normal speech level.
Frequently (50%): Sitting, lifting/carrying/pushing or pulling 1-25 pounds. The use and operation of a motor vehicle for Home Health and Wound Caregivers.
Occasionally (25%): Bending, stooping/kneeling/crouching, climbing ladder/step-stool (varies by area), reaching overhead, lifting/carrying/pushing or pulling 25-50 pounds, grasping/squeezing, ability to hear whispered speech level.
Rarely (10%): Climbing stairs.
Never (0%): Climbing ladder/step-stool (varies by area), operation of a motor vehicle.
Exposure to Elemental Factors
Rarely (10%): Wet/slippery area, chemical solution.
Never (0%): Heat, cold, noise, dust, vibration, uneven surface.
Blood-Borne Pathogen (BBP) Exposure Category
Risk for Exposure to BBP
Schedule Weekly Hours:
40Caregiver Type:
RegularShift:
First Shift (United States of America)Is Exempt Position?
YesJob Family:
NON CONTRACT RNScheduled Days of the Week:
Monday-FridayShift Start & End Time:
8-5
