Disease Specific Nurse Navigator - FT - Days

Mary Washington Healthcare

4d•$39 - $59•Onsite

About The Position

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.

Requirements

Current RN license in Virginia or compact state.
Three years of acute care nursing experience required.
Strong critical thinking, communication, teaching, organizational, and interdisciplinary collaboration skills.

Nice To Haves

Bachelor’s degree in nursing preferred.
Cardiac, medical, care management or population health nursing experience preferred.

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.