Nurse Navigator 1 - Primary Care TBC - Full Time

University of Miami; Coral Gables (FL); Sur place; USD 60 000 - 90 000; Plein temps

Résumé du poste

University of Miami seeks a Nurse Navigator 1 for Primary Care Team-Based Care (TBC) to be the initial contact for patients entering the health system. You will ensure timely scheduling, coordinate care after the first appointment, and support patients throughout the care continuum.

You will liaise between patients, families, caregivers, and the care team, promoting quality patient care and implementing innovative strategies to meet diverse patient needs.

Responsabilités

• Triages new patient appointments to ensure timely scheduling
• Reviews outside medical records for appropriate scheduling
• Assists in overcoming barriers to care and connects to support services
• Educates patients on treatment plans based on diagnosis
• Supports patients throughout the care continuum and counsels on healthy practices
• Collaborates with a multidisciplinary team to determine best treatment
• Facilitates transitions back to primary care after hospital visits

Description du poste

CORE JOB SUMMARY

The Nurse Navigator 1 - Primary Care Team-Based Care (TBC) is the initial point of contact for a patient entering the health system and assures timely scheduling of the first appointment, and coordination of care after completion of the first appointment and supports the patient throughout the care continuum. The Nurse Navigator 1 serves as a liaison between patients, families, caregivers, and the multidisciplinary care team. The incumbent demonstrates a commitment to quality patient care, implements creative and innovative ways to meet the diverse needs of the patients and ensures best practices.

CORE JOB FUNCTIONS

• Triages new patient appointments to the appropriate provider(s) and assures timely scheduling of initial appointments.
• Reviews outside medical records for appropriate scheduling.
• Assess barriers to care and refers to support services, local, and national organizations when needed.
• Educates on the treatment plan for patients based on diagnosis.
• Supports patients throughout the care continuum.
• Counsels individuals and patients on positive health practices.
• Collaborates with a multidisciplinary team of experts to outline the best treatment for patients.
• Performs holistic evaluation of specialty population, making use of enhanced proven techniques and procedures to achieve better results.
• Implements the improvement of patient care, and healthcare policies and resources.
• Mentors other healthcare professionals by functioning as a preceptor or coordinating preceptors for visiting professionals, students, new graduates, and orienteers.
• Maintains professional knowledge by affiliating with professional and technical organizations, and participating in applicable continuing education programs, conferences, seminars, and workshops.
• Adheres to University and unit-level policies and procedures and safeguards University assets. This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.

Department Specific Functions

Provides enhanced clinical nurse navigation for high-risk and medically complex Primary Care patients whose needs extend beyond routine TBC pod management.

Patient Navigation & Education

• Supports multiple Primary Care TBC pods by coordinating care for patients with complex clinical conditions, multiple specialists, recurrent utilization, or complicated transitions of care.
• Navigates complex specialty referrals, diagnostic testing, procedures, and clinical follow-up when additional coordination is needed beyond routine pod workflows.
• Identifies patients requiring enhanced clinical navigation based on clinical complexity, utilization, care transitions, provider/pod referral, or difficulty completing the clinical plan of care.
• Provides patient and caregiver education regarding the clinical plan of care, medication changes, follow-up expectations, warning signs, and when to contact the Primary Care team.

Care Transitions & Continuity

• Facilitates transitions back to Primary Care following hospitalization, emergency department visits, rehabilitation, or other significant episodes of care, ensuring appropriate clinical follow-up.
• Reviews discharge plans, medication changes, pending tests, specialist recommendations, and follow-up requirements and facilitates communication with the Primary Care team.
• Provides targeted clinical follow-up for patients experiencing recurrent ED visits or hospitalizations, working with the Primary Care provider and pod RN to strengthen continuity with Primary Care.
• Ensures clinically relevant information from specialists, hospitals, and other care settings is incorporated in the patient's ongoing Primary Care plan.

Collaboration & Interdisciplinary Coordination

• Coordinates complex clinical care across Primary Care, specialty services, diagnostic services, pharmacy, hospital-based teams, and other clinical services to reduce fragmentation and delays in care.
• Participates in complex case reviews and interdisciplinary TBC discussions for patients requiring enhanced clinical navigation.
• Escalates unresolved clinical concerns to the Primary Care provider and coordinates with the Social Worker when psychosocial or social needs are identified.
• Collaborates with the pod RN to establish clear handoffs and avoid duplication of clinical management activities.

Process Improvement & Quality Assurance

• Tracks patients receiving enhanced navigation until complex clinical coordination needs are resolved and the patient can return to routine management within the TBC pod.
• Identifies recurring clinical coordination barriers and opportunities to improve transitions, commun