Disease Specific Nurse Navigator - FT - Days

Mary Washington Healthcare; Fredericksburg (VA); On-site; USD 54,000 - 81,000; Full time

Job summary

Mary Washington Healthcare seeks a Disease-Specific Nurse Navigator to coordinate inpatient care and transition planning for high-risk patients. You will work with the interdisciplinary team to support disease management, provide education, address barriers to care, and promote safe, coordinated transitions to post-discharge services.

This role aims to improve clinical outcomes, reduce avoidable utilization, and support continuity of care across the healthcare continuum, with post-discharge

Qualifications

• Current RN license in Virginia or compact state.
• Three years of acute care nursing experience required.
• Bachelor's degree in nursing preferred.

Responsibilities

• Identifies high-risk and high-utilization patients and develops individualized plans of care.
• Maintains competency in guidelines and collaborates with providers for evidence-based care.
• Screens patients for disease progression and coordinates post-discharge referrals.
• Provides disease-specific education to patients, families, and care teams.
• Facilitates communication across the care continuum and coordinates follow-up care.
• Serves as a clinical resource for outpatient teams and supports care coordination.
• Reviews readmission trends and data to identify improvement opportunities.
• Develops protocols and best practices to support guideline-driven care.
• Collaborates with leaders and staff to optimize patient outcomes.

Skills

Critical thinking

Communication

Teaching

Organizational skills

Interdisciplinary collaboration

Education

Bachelor's degree in nursing (preferred)

Job description

Start the day excited to make a difference...end the day knowing you did. Come join our team.

Job Summary:

The Disease-Specific Nurse Navigator coordinates inpatient care and transition planning for high-risk patients within designated readmission-reduction populations. Working across the care continuum, the Nurse Navigator partners with the interdisciplinary team to support evidence-based disease management, provide disease-specific education, address barriers to care, and promote safe, coordinated transitions to post-discharge services. This role focuses on improving clinical outcomes, reducing avoidable utilization, and supporting continuity of care.

Essential Functions & Responsibilities

• Identifies high-risk and high-utilization patients within designated disease population(s), assesses readmission risk factors, barriers to care, resource utilization concerns, and opportunities to improve clinical outcomes, and develops individualized plans of care to support safe transitions and reduce avoidable utilization.
• Maintains competency in current evidence-based clinical guidelines and guideline-directed medical therapy for the defined patient population(s) and collaborates with providers to support evidence-based care delivery.
• Screens patients for disease progression, advanced illness, and supportive care needs, including referral to palliative care and other specialty resources when appropriate.
• Provides and reinforces disease-specific education to patients, families, caregivers, and healthcare team members to support self-management and optimal clinical outcomes.
• Facilitates communication of relevant patient information and plans of care across the healthcare continuum, including coordination of follow-up care, referrals to community case management, and post-discharge support services as indicated.
• Serves as a clinical resource for outpatient teams by providing post-discharge support and addressing patient-specific needs related to disease management and care coordination.
• Reviews readmission trends, utilization patterns, and outcome data through chart review, patient and family engagement, and interdisciplinary collaboration to identify improvement opportunities and support process changes.
• Develops and implements protocols, workflows, educational materials, and best practices that support evidence-based, guideline-driven care for the designated patient population(s).
• Serves as a disease-specific clinical resource and collaborates with leaders, physicians, nurses, allied health professionals, and support staff across the continuum to support organizational goals and optimize patient outcomes.
• Participates in meetings, quality initiatives, regulatory reviews, and other activities that support the designated patient population(s).
• Maintains current knowledge through self-directed learning, professional development activities, and participation in local and national professional networks.
• Performs other duties as assigned.

Qualifications

• Current RN license in Virginia or compact state.
• Three years of acute care nursing experience required.
• Bachelor's degree in nursing preferred.
• Cardiac, medical, care management or population health nursing experience preferred.
• Strong critical thinking, communication, teaching, organizational, and interdisciplinary collaboration skills.

MWHC will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status (EOE). We are also committed to equitable and transparent compensation practices and comply with all applicable pay transparency and pay equity laws.

Required

Physical Requirements: Constant (67-100% of workday) use of arms and hands; frequent (34-66% of workday) standing, walking, and sitting; occasional (0-33% of workday) bending, stooping, and squatting; ability to lift 35 lbs.; ability to push and pull up to 20 lbs.; auditory and visual skills to include color determination.

Mental Requirements: Possesses critical thinking and analytical skills. Ability to multi-task. Ability to communicate effectively and collaborate with a multi-disciplinary team. Capacity to cope with difficult situations. Ability to tolerate irregular hours including evenings, nights, and weekends.

Environmental Requirements and Exposure Hazards: Potential risk of exposure to radiation and toxic chemicals. Potential for exposure to bloodborne pathogens; must be able to wear appropriate personal protective equipment.

"It is the policy of Mary Washington Healthcare to provide reasonable accommodations to qualified individuals with a disability who are applicants for employment or Associates."

Compensation Pay Range:

$39.44 - $59.15