Nurse Navigator 1 - Primary Care TBC - Full Time North Miami

University of Miami•North Miami, FL

About The Position

The Nurse Navigator 1 – Primary Care Team-Based Care (TBC) serves as an initial point of contact for patients entering the health system, helping ensure timely scheduling of initial appointments and coordinating care after those appointments. The role supports patients throughout the care continuum and serves as a liaison among patients, families, caregivers, and the multidisciplinary care team, with a focus on quality patient care and meeting patients’ diverse needs. In this department-specific role, the nurse provides enhanced clinical navigation for high-risk and medically complex Primary Care patients whose needs extend beyond routine TBC pod management. The position coordinates complex referrals, diagnostic testing, procedures, follow-up, and transitions between care settings; educates patients and caregivers about care plans; and collaborates with Primary Care, specialty services, diagnostic services, pharmacy, hospital teams, and other clinical services. The nurse tracks patients through complex coordination until they can return to routine TBC pod management and identifies opportunities to improve continuity and care processes.

Requirements

Bachelor’s degree in a relevant field.
At least 2 years of relevant experience.
Valid State of Florida RN license.
Ability to learn new procedures, technologies, and protocols and adapt to changing priorities and work demands.
Ability to collaborate with others and contribute to a team environment.
Proficiency with office software, technology, and relevant computer applications.
Strong written and verbal communication skills.

Responsibilities

Triage new patient appointments to appropriate providers and ensure timely scheduling of initial appointments.
Review outside medical records to support appropriate scheduling.
Assess barriers to care and refer patients to support services and local or national organizations when needed.
Educate patients about treatment plans based on their diagnoses.
Support patients throughout the care continuum and counsel individuals and patients on positive health practices.
Collaborate with multidisciplinary experts to determine appropriate patient treatment.
Perform holistic evaluations of the specialty population using enhanced, evidence-based techniques and procedures.
Contribute to improvements in patient care, healthcare policies, and resources.
Mentor healthcare professionals and serve as a preceptor or coordinate preceptors for visiting professionals, students, new graduates, and orientees.
Maintain professional knowledge through professional and technical organizations and continuing education programs, conferences, seminars, and workshops.
Follow University and unit-level policies and procedures and safeguard University assets.
Coordinate care for complex Primary Care patients with multiple specialists, recurrent utilization, or complicated transitions of care.
Navigate complex specialty referrals, diagnostic testing, procedures, and clinical follow-up beyond routine pod workflows.
Identify patients needing enhanced clinical navigation based on clinical complexity, utilization, care transitions, referrals, or difficulty completing the clinical plan of care.
Educate patients and caregivers about the clinical plan of care, medication changes, follow-up expectations, warning signs, and when to contact the Primary Care team.
Facilitate transitions back to Primary Care after hospitalization, emergency department visits, rehabilitation, or other significant episodes of care.
Review discharge plans, medication changes, pending tests, specialist recommendations, and follow-up requirements, and facilitate communication with the Primary Care team.
Provide targeted clinical follow-up for patients with recurrent emergency department visits or hospitalizations in collaboration with Primary Care providers and pod RNs.
Ensure relevant information from specialists, hospitals, and other care settings is incorporated into the patient’s ongoing Primary Care plan.
Coordinate complex clinical care across Primary Care, specialty services, diagnostic services, pharmacy, hospital-based teams, and other clinical services.
Participate in complex case reviews and interdisciplinary TBC discussions for patients requiring enhanced clinical navigation.
Escalate unresolved clinical concerns to the Primary Care provider and coordinate with the Social Worker when psychosocial or social needs are identified.
Collaborate with the pod RN to establish clear handoffs and avoid duplication of clinical management activities.
Track patients receiving enhanced navigation until complex coordination needs are resolved and they can return to routine TBC pod management.
Identify recurring clinical coordination barriers and opportunities to improve transitions, communication, and continuity across Primary Care.