Ambulatory Nurse Navigator

Parkview Health•Fort Wayne, IN

About The Position

Primarily responsible for promoting the overall health and welfare of identified patients by fostering collaboration at the office level and across the health system. Serves as the patient’s advocate, assessing, managing, and monitoring individualized primary and social needs, as well as assessing patient health status using remote patient monitoring (RPM) technologies. Builds and maintains strong relationships with patients, families, and caregivers to develop and update personalized health goals that engage and empower patients and improve health outcomes. Provides care coordination and identifies and manages patient populations with unmet primary or social needs, high readmission risk, and uncontrolled chronic conditions using EMR, registries, and reporting. Coordinates continuity of care and transitional care management after hospital admissions, discharges, and ED visits. Monitors patients’ vital signs, symptoms, and medication adherence using RPM technologies; provides timely interventions based on assessment findings; participates in ongoing RPM training; and conducts comprehensive and preventive screenings. The posting also mentions outreach to patients with gaps in, but the statement is incomplete.

Requirements

Associate of Science in Nursing (ASN) from an accredited program.
Valid Indiana Registered Nursing License.
Current BLS certification.

Nice To Haves

Bachelor of Science in Nursing (BSN) preferred.
Minimum of 3 years in an ambulatory care or hospital setting preferred.

Responsibilities

Promote patients’ overall health and welfare through collaboration at the office level and across the health system.
Advocate for patients by assessing, managing, and monitoring their individualized primary and social needs and health status using RPM technologies.
Build and maintain relationships with patients, families, and caregivers to develop and update personalized health goals.
Provide care coordination to patients.
Identify and manage patients with unmet primary or social needs, high readmission risk, and uncontrolled chronic conditions using EMR, registries, and reporting.
Coordinate continuity of care and transitional care management after hospital admissions, discharges, and ED visits.
Monitor patients’ vital signs, symptoms, and medication adherence using RPM technologies.
Provide timely interventions based on assessment findings.
Participate in ongoing training to enhance RPM skills.
Conduct comprehensive and preventive patient screenings.
Conduct outreach to patients with gaps in care; the posting does not specify further because the statement is incomplete.