Clinical Services Navigator RN

UVA Health Northern Virginia & Culpeper • Gainesville, VA

23h • Onsite

About The Position

We are welcoming a new era in healthcare where achieving good health is just the beginning. At UVA Health Northern VA & Culpeper, we believe in caring for the whole person by getting to know – and making connections with – our patients. By combining the talent and expertise of our people, the breadth of capabilities across our system, and our commitment to helping our communities get better and stay healthy, we are improving the patient experience. As a UVA Health Northern VA & Culpeper team member, you will have a voice in patient care decisions, support the most advanced medical technologies and feel a strong sense of satisfaction from making a difference in people’s lives every day.

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.
• Demonstrates knowledge of orthopedic care pathways, including ERAS protocols, pain management principles, and discharge criteria.

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.

Responsibilities

• Facilitate care coordination from acute to ambulatory settings.
• Collaborate with Physicians, Case Managers, and other healthcare team members to coordinate care and follow-up appointments.
• Serve as a resource for care coordination.
• Maintain current knowledge of available community resources, post-acute care, and ambulatory options.
• Provide patient and family education regarding the surgical pathway, ERAS protocols, recovery expectations, and discharge planning.
• Reinforce health promotion, mobility, and illness prevention strategies in collaboration with the care team.
• Review patient records to identify needs, barriers, and opportunities for support across the care continuum.
• Recommend and connect patients/families to appropriate community resources and support services.
• Provide ongoing patient phone contact pre- and post-operatively to ensure understanding, readiness, and continuity of care.
• Collaborate with interdisciplinary teams to achieve desired quality outcomes (e.g., reduced LOS, readmission prevention, infection reduction, and same-day discharge targets).
• Monitor patient outcomes and pathway adherence to identify trends and opportunities for improvement.
• Apply principles of safety and infection prevention in all patient interactions.
• Participate in quality initiatives, audits, and process improvement activities to support departmental and organizational goals.
• Function as a central point of contact for patients, ensuring consistent messaging across the care team.
• Collaborate effectively with physicians, nursing, PT/OT, anesthesia, and case management to coordinate care and discharge planning.
• Participate in interdisciplinary rounds, staff meetings, and care conferences to support shared goals.
• Identify opportunities for process improvement and communicate feedback from staff and patients to leadership.
• Assess patient readiness for surgery and recovery by reviewing records, identifying barriers, and escalating concerns appropriately to providers or case management.
• Track and document patient progress across the continuum to ensure alignment with clinical pathways and program metrics.
• Support transitions of care by scheduling follow-up appointments, coordinating services, and ensuring patients understand next steps in their care journey.
• Maintain up-to-date knowledge of hospital services, community resources, post-acute care, and ambulatory options to support patient needs.
• Perform additional duties as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level