Clinical Services Navigator RN

UVA Community Health•Gainesville, VA

1d•Onsite

About The Position

The Clinical Services Navigator will facilitate care coordination from acute to ambulatory and is a valued member of the healthcare team. They collaborate with Physicians, Case Managers, and other members of the healthcare team to facilitate coordination of care and follow-up appointments to the ambulatory setting. Collaborates with Case Managers for guidance with medically and/or psychosocially complex cases. Serves as a resource for care coordination. Maintains current knowledge of available community resources, post-acute care and ambulatory options.

Requirements

RN required.
Demonstrates effective communication skills to provide patient education.
Demonstrates effective communication skills to discuss case management, financial, clinical issues with hospital-based case managers, physicians, outside agencies and facilities, nurses, and other healthcare professionals in the community.
Autonomous, self-starter with the ability to make independent decisions.
Organized with effective time management skills.
Detail oriented with ability to facilitate change and affect positive results.
Proficient in computer/web-based tools.
Constant standing, frequently walking, and bending/stooping.
Proficient communicative, auditory, and visual skills.
Attention to detail and ability to write legibly.
Ability to lift/push/pull 100 lbs. For any weight over 35 lbs., use Safe Handling Equipment.

Nice To Haves

4 Year/Bachelor's Degree preferred.
2 years of experience preferred.
5 years of clinical experience with knowledge in the care of disease specific population preferred.
Certified in specialized area preferred.
National specialty certification required, or obtained within 2 years, if applicable to position.
N/A

Responsibilities

Provides patient and family education regarding the surgical pathway, ERAS protocols, recovery expectations, and discharge planning.
Reinforces health promotion, mobility, and illness prevention strategies in collaboration with the care team.
Reviews patient records to identify needs, barriers, and opportunities for support across the care continuum.
Recommends and connects patients/families to appropriate community resources and support services.
Provides ongoing patient phone contact pre- and post-operatively to ensure understanding, readiness, and continuity of care.
Collaborates with interdisciplinary teams to achieve desired quality outcomes (e.g., reduced LOS, readmission prevention, infection reduction, and same-day discharge targets).
Monitors patient outcomes and pathway adherence to identify trends and opportunities for improvement.
Applies principles of safety and infection prevention in all patient interactions.
Participates in quality initiatives, audits, and process improvement activities to support departmental and organizational goals
Demonstrates strong interpersonal and communication skills in interactions with patients, families, and colleagues.
Functions as a central point of contact for patients, ensuring consistent messaging across the care team.
Collaborates effectively with physicians, nursing, PT/OT, anesthesia, and case management to coordinate care and discharge planning.
Participates in interdisciplinary rounds, staff meetings, and care conferences to support shared goals.
Identifies opportunities for process improvement and communicates feedback from staff and patients to leadership.
Demonstrates knowledge of orthopedic care pathways, including ERAS protocols, pain management principles, and discharge criteria.
Assesses patient readiness for surgery and recovery by reviewing records, identifying barriers, and escalating concerns appropriately to providers or case management.
Tracks and documents patient progress across the continuum to ensure alignment with clinical pathways and program metrics.
Supports transitions of care by scheduling follow-up appointments, coordinating services, and ensuring patients understand next steps in their care journey.
Maintains up-to-date knowledge of hospital services, community resources, post-acute care, and ambulatory options to support patient needs.