Nurse Navigator-Cancer Rehab

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Job Summary:

Key Position Details:

Nurse Navigator role will support cancer rehabilitation patients. This may require employee to float between ANW, United, Edina, WestHealth, and Mercy depending on patient needs.

Hybrid role -

During training/orientation- 3-4 days per week will be onsite.

After training/orientation- likely 1-2 days onsite, 3-4 days remote.

• Full time position
• 8-hour, day shifts
• No weekends

Job Description:

Provides care management support to panel of patients who require specialty services integrated and in support of their overall plan of care. Interacts with and supports the specialty care providers, primary care providers and the interdisciplinary care team across the continuum of care. Assesses plans, implements, documents, coordinates, monitors, evaluates, and updates the plan of care by collaborating with all members of the health care team to provide evidenced based care, leveraging nationally recognized guidelines as appropriate. Researches, evaluates and recommends resources to meet medical and non-medical needs of patients and families. Works to establish collaborative processes that promote quality and cost effective care that optimizes the physical and psychosocial health of patients across the health care continuum. Responsible for supporting decisions that impact health care outcomes, resource allocation and customer experience. Acts as a primary contact for the care team to assist in navigation and complexity management. Engages in quality improvement initiatives and program development. Could require work and travel to multiple locations in support of the patient and department.

Principle Responsibilities

• Assessment.
  • Gathers all relevant data and obtains information by communicating with the patient, family, healthcare provider, other members of the healthcare delivery team and patient's community support network including external healthcare providers and agencies.
  • Utilizes assessment by other care management professionals in primary care and inpatient areas as patient needs those services.
• Planning.
  • Works with the patient, family and healthcare provider to develop a treatment plan which enhances patient outcomes.
  • Initiates and implements plan modifications as necessary through monitoring and re-evaluation to accommodate changes.
  • Incorporates evidence-based nursing practice and takes into consideration current statutes, rules and regulations when developing the plan of care.
  • Supports planning across the continuum of specialty care services and in collaboration with other care management professionals in primary care and inpatient areas as patient needs those services.
  • Supports planning with community resources and external healthcare agencies to provide broadest available integrated network of support as needs indicate.
  • Maintains high level oversight of the specialty plan of care in conjunction with the overall integrated plan and assures goals are met and/or addressed.
• Implementation and Coordination.
  • Works with patient, family, healthcare providers and community supports to coordinate needed services.
  • Identifies barriers and works with patient and family to resolve them.
  • Facilitates communication between patient, family and all members of the health care team.
  • Assures health care benefits have been reviewed and plan has been coordinated with the insurance provider. Alternate sources of funding are identified if available for services not eligible for benefits.
  • Addresses complex communication and planning issues as patient receives services across the specialty care continuum (in particular for patients with multiple consultants and services).
  • Leads and supports transition and discharge planning for patients moving between levels of care.
  • Transition patient back to primary care provider and care manager when specialty services are no longer needed.
  • Provide education and information for patient related to diagnosis, treatment, and quality of life.
• Monitoring and Evaluation.
  • Follows the patient over time, across sites of care as long as specialty care is needed, to measure effectiveness of the plan.
  • Adapts plan to meet changing needs.
  • Communicates with patient, family and healthcare providers about changes in plan.
  • Coordinates, implements and documents plan of care and outcomes.
  • Documents plan of care in electronic medical record.
• Leadership.
  • Supervises and delegates to care management support staff tasks that contribute to the plan.
  • Addresses barriers to the plan.
  • Acts in an oversight capacity through all episodes of care, and collaborates with care managers and other. healthcare professionals in other specialty or inpatient areas and the community to assure overall plan is met.
• Participates in staff, departmental meetings and assists with identification and resolution of problems, ideas and opportunities.
  • Communicates issues and decisions relating to committee and project work to other team members, management, and sponsors.
  • Participates in quality and performance improvement activities related to specialty care practice.
  • Incorporates performance improvement and best practices into specialty care practice.
• Other duties as assigned.

Required Qualifications

• Bachelor's degree in nursing

Preferred Qualifications

• 2 to 5 years of nursing experience required with a minimum of 3 years of experience in area of clinical specialty, care coordination or care management
• 0 to 2 years of clinical experience in outpatient and hospital settings
• 0 to 2 years of progressive leadership through engagement in performance improvement and program development

Licenses/Certifications

• Licensed Registered Nurse - MN Board of Nursing required
• Licensed Registered Nurse - WI Dept of Safety & Professional Services required upon hire if providing care to patients over the phone, through e-visits, virtual visits, or medical messages and the patient is in Wisconsin at the time of the care
• BLS Tier 1 - Basic Life Support - Multisource required
• Case Manager Certification preferred

Physical Demands

• Sedentary:
• Lifting weightUp to 10 lbs. occasionally, negligible weight frequently