Nurse Navigator 1 - Primary Care TBC - Full Time

University of Miami•Coral Gables, FL

4d•Onsite

About The Position

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. This role provides enhanced clinical nurse navigation for high-risk and medically complex Primary Care patients whose needs extend beyond routine TBC pod management. It supports multiple Primary Care TBC pods by coordinating care for patients with complex clinical conditions, multiple specialists, recurrent utilization, or complicated transitions of care. The Nurse Navigator navigates complex specialty referrals, diagnostic testing, procedures, and clinical follow-up when additional coordination is needed beyond routine pod workflows. They identify patients requiring enhanced clinical navigation based on clinical complexity, utilization, care transitions, provider/pod referral, or difficulty completing the clinical plan of care. The role also involves facilitating transitions back to Primary Care following hospitalization, emergency department visits, rehabilitation, or other significant episodes of care, ensuring appropriate clinical follow-up. This includes reviewing discharge plans, medication changes, pending tests, specialist recommendations, and follow-up requirements and facilitating communication with the Primary Care team. Additionally, the Nurse Navigator 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. They ensure clinically relevant information from specialists, hospitals, and other care settings is incorporated into the patient's ongoing Primary Care plan. The position also involves coordinating 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. It includes participating in complex case reviews and interdisciplinary TBC discussions for patients requiring enhanced clinical navigation. The Nurse Navigator escalates unresolved clinical concerns to the Primary Care provider and coordinates with the Social Worker when psychosocial or social needs are identified. They collaborate with the pod RN to establish clear handoffs and avoid duplication of clinical management activities. Finally, the role tracks patients receiving enhanced navigation until complex clinical coordination needs are resolved and the patient can return to routine management within the TBC pod, and identifies recurring clinical coordination barriers and opportunities to improve transitions, communication, and continuity across Primary Care.

Requirements

Bachelor’s degree in relevant field required
Minimum 2 years of relevant experience required
Valid State of Florida RN license required
Learning Agility: Ability to learn new procedures, technologies, and protocols, and adapt to changing priorities and work demands.
Teamwork: Ability to work collaboratively with others and contribute to a team environment.
Technical Proficiency: Skilled in using office software, technology, and relevant computer applications.
Communication: Strong and clear written and verbal communication skills for interacting with colleagues and stakeholders.

Nice To Haves

Refer to department description for applicable certification requirements

Responsibilities

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.
Provides enhanced clinical nurse navigation for high-risk and medically complex Primary Care patients whose needs extend beyond routine TBC pod management.
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.
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 into the patient's ongoing Primary Care plan.
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.
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, communication, and continuity across Primary Care.