Nurse Navigator, Oncology

University of Maryland Medical System•Easton, MD

2d•$41 - $61

About The Position

At Shore Regional Health, you can learn, grow and make a lasting impact on patients and families. You’ll experience the support of a collaborative work environment and a sense of collegiality unlike any other. Our comprehensive system has many locations and practice options to choose from throughout the beautiful Eastern Shore of Maryland. As a Nurse at UMMS, you’ll experience: A supportive and collaborative work environment An Achievable Professional Advancement Model: Opportunities to progress in function, skills, and pay through our achievable promotion schedule. The opportunity to work in a specialized care environment at an Academic Medical Center with a nursing-centered care model and Magnet Designation. A comprehensive benefits package including health, vision, and dental coverage including prescription drug coverage, Tax-Free Savings Plans, and more! A competitive wage scale: Annual merit increases and a base wage scale that is measured against market standards.

Requirements

Associate Degree in Nursing required
Minimum three (3) years of previous nursing experience required
One (1) year previous case management experience
Current Maryland RN license required
BLS required

Nice To Haves

Experience with quality-based reimbursement models, utilization management, or outpatient medical practice preferred
Bachelor of Science in Nursing preferred

Responsibilities

Identifies high risk patients through use of prospective risk stratification tool (e.g., high risk diagnosis, START, LACE, etc.)
Completes comprehensive psycho-social assessments, consultation, treatment, and discharge recommendations, to include remote patient monitoring
Provides complex care planning to high-risk patients in the community, via telephone calls, in-person meetings, telehealth, etc., according to established program protocols and policies
Accepts responsibility for patients’ Transitions of Care, coordinating provisions for discharge from facilities including follow-up appointments, home health, community services, transportation, etc., in order to maintain continuity of care
Coordinates and facilitates communications between all patient settings, including acute care, ambulatory, short stay, skilled nursing, palliative care, and hospice
Promotes patient self-management, educating patients on disease specific needs, medication, access to care, self-care support, to improve clinical outcomes and increase patient self-efficacy
Identifies pts needs and makes appropriate referrals to programs/services (i.e. social worker, pharmacist, community agencies, etc.)
Consults regularly with the inpatient team, PCP, supervisor, transitional team, and other team members to ensure that the transition plan remains relevant, appropriate, and achievable to changing patient status and/or goals
Meets with patients while in the hospital to establish rapport and smooth transition to outpatient setting and follow-up
Maintains effective relationships with patients and families, community-based agencies, and payers, facilitating interdisciplinary team meetings
Collaborates and implements plans in accordance with established policies, prioritizing patient care goals and needs. Meeting with patients, patients’ family and caregivers as needed to discuss transitional care and treatment plan
Works proactively with patients, caregivers, and patients care team to identify an advanced care plan, including Advanced Directives and MOLST
Implements plan of care for the patient by performing evidence-based interventions and treatments specific to the diagnosis or problem of the patient; administers treatment such as, lab draws, start IVs, injections, nebulizer treatments, wound care as directed by provider, and monitors patients according to their needs and acuity level. Performs symptom-based standing orders and plan of care
Maintains accurate and complete records, initiates and oversees data entry into IT systems, documents all care rendered, pertinent patient information, all communications, and all care management decisions in appropriate database/electronic record
Takes the lead on programs, identifying improvements and putting changes in place to better assist the high-risk population. Provides education to the team on information that will benefit patient outcomes
Perform all other duties as assigned.