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, coordinating timely first appointments and supporting patients throughout the care continuum. The role serves as a liaison among patients, families, caregivers, and the multidisciplinary care team, with a commitment to quality care and meeting patients’ diverse needs. In this department, the Nurse Navigator provides enhanced clinical navigation for high-risk and medically complex Primary Care patients whose needs exceed routine TBC pod management. The position supports multiple Primary Care TBC pods by coordinating complex referrals, testing, procedures, follow-up, and transitions of care. It provides patients and caregivers with education about care plans, medications, follow-up expectations, warning signs, and contacting the Primary Care team. The role also coordinates with clinical and support services, tracks patients until complex needs are resolved, and identifies opportunities to improve care coordination and continuity.

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 work collaboratively 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 on treatment plans based on diagnosis and provide guidance on medications, follow-up expectations, warning signs, and when to contact the Primary Care team.
Support patients throughout the care continuum and counsel individuals and patients on positive health practices.
Coordinate enhanced navigation for patients with complex conditions, multiple specialists, recurrent utilization, complicated care transitions, or difficulty completing clinical plans.
Coordinate complex specialty referrals, diagnostic testing, procedures, and clinical follow-up beyond routine pod workflows.
Facilitate transitions back to Primary Care after hospitalization, emergency department visits, rehabilitation, or other significant care episodes.
Review discharge plans, medication changes, pending tests, specialist recommendations, and follow-up requirements, and communicate relevant information to 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.
Coordinate 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.
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 on handoffs and to 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.
Collaborate with a multidisciplinary team to outline appropriate treatment and perform holistic evaluations of the specialty population using proven techniques and procedures.
Contribute to improvements in patient care, healthcare policies, and resources.
Mentor healthcare professionals as a preceptor or coordinate preceptors for visiting professionals, students, new graduates, and orientees.
Maintain professional knowledge through professional and technical affiliations and participation in continuing education, conferences, seminars, and workshops.
Adhere to University and unit-level policies and procedures and safeguard University assets.
Perform other duties or responsibilities as necessary.