Navigates patient and family members through the intake, diagnosis, treatment, and follow-up of the patient throughout the continuum of care ensuring smooth transitions between care settings. Collaborates with a multi-disciplinary team to support patients and families in addressing the following dimensions of care: education, psychosocial needs, advocacy, and continuity of care. Completes a nursing assessment to identify the patient's individualized needs and collaborates with multidisciplinary teams across ambulatory and acute sites and departments to develop an interdisciplinary plan of care. Supports the patient and family by providing education, addressing psychosocial needs, advocating, providing continuity of care, and mitigating barriers to care. Navigates patients and family members throughout the intake, diagnosis, treatment, and follow-up of the patient throughout the continuum of care. Provides expert clinical advice to the multidisciplinary team in designing collaborative teaching plans/programs and in planning/providing patient/family education and discharge planning including wellness and health maintenance within designated specialty. Coordinates timely, seamless, evidenced based care across the care continuum resulting in optimal patient outcomes. Evaluates, selects, or designs patient education materials on specific disease site programs. Provides individual and group-based education and outreach to patients (new, existing, and potential), internal care teams, and members of the community. Manages patient care access points for new, potential, and existing patients including engaging in daily rounding, intake of patient calls, and self-referral tools. Intakes and connects both provider-referral and self-referral patients to appropriate care teams. Designs and facilitates support group sessions for medical and surgical patient populations. Facilitates appropriate and prompt access to primary care providers, physician specialists, and other services as needed. Monitors medical and surgical patient registries to identify patients overdue for visits, labs, or referrals; arranges follow-up services as appropriate and updates health information records. Supports service line growth initiatives to meet or exceed budgeted volumes. Monitors physician referral patterns and partners with leadership to engage in community outreach. Assist leadership in developing program vision, goals, and objectives. Assists in the development, implementation, and maintenance of quality programs that include best practice patient care outcomes, including quality of life and enhanced patient loyalty. Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
Job Type
Full-time
Career Level
Mid Level
Number of Employees
11-50 employees