Transition Nurse Navigator (RN)

Transition Nurse Navigator

Good Shepherd Hospital

Full Time Days with some flexibility.

Navigates patient and family members through the diagnosis, treatment, and follow-up of the patient throughout the continuum of care ensuring smooth transitions between care settings. Collaborates with a multi-disciplinary team to support patients and families in addressing the following dimensions of care: education, psychosocial needs, advocacy, and continuity of care.

Major Responsibilities:

• Provides continuity of care by ensuring smooth transitions between care settings.  Develops a relationship with patient and their multidisciplinary team to facilitate and/or navigate through subsequent treatment and follow-up to reflect continuity of care.
• Completes a nursing assessment to identify the patient's individualized needs and collaborates with multidisciplinary team and other departments to develop an interdisciplinary plan of care.
• Supports the patient and family by providing education, addressing psychosocial needs, advocating, providing continuity of care and identifying barriers to care.  Navigates patients and family members throughout the diagnosis, treatment and follow-up of the patient throughout the continuum of care.
• Provides expert clinical advice to the multidisciplinary team in designing collaborative teaching plans/programs and in planning/providing patient/family education and discharge planning including wellness and health maintenance within designated specialty.
• Coordinates timely, seamless, evidenced based care across the care continuum resulting in best patient outcomes.
• Evaluates, selects or designs patient education materials on specific disease site programs.  Provides education and outreach programs to patients, Advocate staff and to members of the community.
• Assist leadership in developing program vision, goals and objectives.  Assists in the development, implementation and maintenance of quality programs that include best practice patient care outcomes including quality of life, and enhanced patient loyalty.
• Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served.  
• Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures.
• Age-specific information is developed further in the departmental job standards.

Licensure, Registration, and/or Certification Required:

Registered Nurse license issued by the state in which the team member practices, and
 

Education Required:

Bachelor's Degree in Nursing.

Experience Required:

Typically requires 5 years of experience in nursing that includes performing nursing assessments, care plan development, and educating patients.   

Knowledge, Skills & Abilities Required:

Working knowledge of the components of quality and acute patient care needs.

Maintains clinical expertise to effectively manage physical, emotional, psychosocial and spiritual needs of patients throughout the care continuum. 

Excellent analytical and interpersonal communication skills necessary to negotiate with families, patient, physicians, and third-party payers. 

Demonstrated ability to work well with physicians and other professionals in a direct and positive manner.

Physical Requirements and Working Conditions:

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.