Nurse Navigator – Chronic Disease & Elder Care Programs

Bayshore HealthCare; Canada; Remote; CAD 40,000 - 56,000; Part time

Job summary

Bayshore HealthCare's Carepath Digital Health unit is seeking a skilled Nurse Navigator (RN) to support clients with chronic disease and elderly-related needs through education, coaching and care navigation. This remote, part-time role focuses on coordinating second-opinion consultations and guiding treatment options.

The ideal candidate is a registered nurse in good standing, with at least five years of clinical experience, excellent communication and data-entry skills, and the ability to work

Qualifications

• Current registration in good standing as a Registered Nurse in the province of practice.
• Minimum five years of proven clinical experience in managing clients with acute and chronic conditions.
• Knowledge of RNAO and CNO Best Practice Guidelines.
• Motivational interviewing skills/experience an asset.
• Strong critical thinking and problem-solving skills.
• Knowledge of public and private health care options, home care and senior living systems.
• Ability to work independently and with teams.
• Excellent telephone and customer service skills.
• Excellent written and verbal communication skills; bilingual (French and English) an asset.
• Advanced computer skills (MS Word, Excel, Outlook, PowerPoint).

Responsibilities

• Assess the client’s specific program needs.
• Facilitate access to second opinion consultations and gather necessary information and records.
• Coordinate post-second-opinion conferences with clients and families.
• Explain recommended treatment plan options and options.
• Navigate the implementation of conference recommendations.
• Provide health coaching using motivational interviewing techniques.
• Assess health coaching outcomes using standardized tools.
• Document all client-related activities in the electronic database.
• Maintain accurate client records to meet reporting requirements.
• Participate in quality improvement initiatives and ongoing education.
• Maintain confidentiality and adhere to policies.
• Work remotely with flexible hours (22 hours/week).

Skills

Clinical nursing experience

Motivational interviewing

Critical thinking

Communication skills

Data entry accuracy

MS Office (Word/Excel/Outlook/PowerPo

Team collaboration

Independent work

Bilingual (English/French)

Education

Bachelor of Science in Nursing (BSN)

Registered Nurse in good standing

Tools

Microsoft Word

Excel

Outlook

PowerPoint

Job description

Bayshore HealthCare is one of the Canada’s leading providers of home and community health care services and is a privately owned company. Bayshore HealthCare is proud to showcase its achievement as a Platinum member of Canada’s Best Managed Companies Program every year since 2006. Bayshore Healthcare is also recognized as Canada’s Best Employers in Forbes 2023 list. Carepath Digital Health is a Canadian virtual healthcare navigation service owned by Bayshore HealthCare that helps individuals and families manage complex medical conditions, cancer diagnoses, chronic illnesses, and mental health needs.

CarePath Digital Health is seeking a highly skilled and compassionate Nurse Navigator (Registered Nurse) to join our esteemed team.

Job Summary: A Nurse Navigator at Carepath practices within the standards and scope of practice established by the nursing regulatory body in their province of practice. They play a vital role in supporting clients living with chronic disease and elderly-related needs, aiming to enhance health outcomes and quality of life. This includes assisting clients seeking a second opinion through our partnership with the Cleveland Clinic and providing health coaching, education and navigation, using evidence-based strategies to help clients better manage their unique needs. The Nurse Navigator promotes clients' health and quality of life through education, support, empowerment, and advocacy. The Nurse Navigator collaborates with clients, families, and the Carepath team to enhance care.

Duties and Responsibilities

• Assess the client’s specific program needs.
• Facilitate access to the provider of second opinion consults:
  • Collect necessary information (condition-specific questionnaires) and consent.
  • Support the collection of medical records required for the second opinion.
  • Arrange for and participate in the post-second-opinion conference with the client and their families to discuss the results.
  • Provide an explanation of the recommended treatment plan options as required.
  • Navigate the implementation of the recommendations of the conference.
  • Assist with any follow-up questions back to the second opinion provider.
  • Assist with setting up any treatment options.
• Utilize standard tools to assess the client’s need for health coaching, considering the individual's knowledge of the condition, stability of the condition and/or motivation to self-manage their condition.
• Provide health coaching using motivational interviewing techniques to assist clients with goal setting based on strategies developed for the individual’s readiness to learn.
• Assess client’s health coaching outcomes using standardized tools.
• Guide the client to alternate treatment location(s) if requested.
• Document all client-related activities (tasks, phone calls and emails) in the client's electronic database.
• Ensure client records are maintained, and data are accurate to meet program reporting requirements.
• Participate in program quality activities and continuous improvement initiatives in keeping with the company’s Quality Management System and ensure best practice is reflected.
• Maintain skills and competencies by participating in ongoing internal and/or external continuing education activities.
• Adhere to all program and organizational Policies and Procedures.
• Participate in proactive Health and Safety activities while performing all duties. Is responsible for notifying the immediate Supervisor of any Health and Safety risks or concerns.
• Maintains confidentiality of client and corporate information and discusses the same with appropriate Carepath and/or Bayshore personnel.
• Completes other tasks as requested.

Reporting Relationship

The Nurse Navigator reports directly to the Lead Nurse Practitioner / Program Director, Chronic Disease & Elder Care Programs.

Work Location: Remote.

Operating Hours: Candidates must be available to work part-time (22 hours /weekly). Operating from Monday to Sunday, hours are flexible.

Qualifications

• Current registration in good standing as a Registered Nurse in the province of practice.
• Minimum five years of proven clinical experience in managing clients with both acute and chronic medical conditions. Experience in a senior care environment or working with clients with aging-related needs is also preferred.
• Knowledge of RNAO and CNO Best Practice Guidelines.
• Motivational interviewing skills/experience an asset.
• Strong critical thinking and problem-solving skills.
• Knowledge of public and private health care options, home care and senior living systems.
• Able to work well with team members internally and externally with the organization.
• Required to work independently.
• Requires advanced knowledge of computer programs (Microsoft Word, Excel, Outlook, PowerPoint).
• Mindful of the accuracy and thoroughness of data entry for reporting requirements.
• Excellent telephone and customer service skills.
• Excellent written and verbal communication skills that include active listening.
• Bilingual (French and English) an asset.

At Bayshore Healthcare, we are committed to fair, equitable, and transparent compensation practices. Base salary offered within an established range are determined using clearly defined criteria, including skills, experience, and overall organizational impact. All offers are thoughtfully aligned with internal equity and external market competitiveness. We strive to create a high-quality and safe environment for both our team members and the clients and patients we serve is a top priority. Depending on provincial regulations and the nature of the role, new hires may be required to provide proof of vaccination against certain illnesses, such as COVID-19, Hepatitis, or seasonal influenza. Recruiters will provide any role-specific requirements.

Our Equity, Diversity, and Inclusion standards shape our vision of being the difference in the lives of those we care for, collaborate with, and support within our communities.

We take pride in cultivating a culture of belonging, one where individual differences are embraced and celebrated, and where programs, resources, and policies are designed to support each person’s purpose, potential, and well-being.

At Bayshore, we are equally committed to fostering an inclusive and accessible workplace and operate in full compliance with all provincial and territorial Human Rights and accessibility legislation.

To ensure an inclusive recruitment and selection process, candidates are encouraged to share any accommodation needs they may have.