Nurse Navigator - MGH

Mass General Brigham•Boston, MA

52d•Hybrid

About The Position

The MGH Palliative Care RN Navigator (per diem) for the Inpatient Palliative Care Inpatient Consult Service serves as a central coordinator in managing referrals, patient flow, and care transitions for patients with serious or complex illness. This role is responsible for receiving inpatient palliative care consult referrals from a variety of sources, including inpatient providers, outpatient clinics, and the emergency department, and collaborating with referring clinicians to obtain additional clinical and psychosocial information necessary to appropriately triage and prioritize referrals. Prioritization is based on symptom burden, acuity of illness, goals-of-care needs, and patient/family support requirements to ensure patients with the most urgent palliative care needs receive timely intervention. The RN Navigator facilitates communication and coordination among interdisciplinary teams and specialty services to promote continuity, consistency, and alignment of care plans across the continuum. The role may also include participation in interdisciplinary huddles with Emergency Department, Palliative Care, Case Management, and other clinical teams to assess patient appropriateness for established care pathways and program protocols. The RN Navigator educates clinicians and staff on pathway criteria, supports appropriate patient entry into designated programs, and monitors patient progression through the continuum of care to ensure timely placement into the next appropriate level of care or disposition setting. In collaboration with these clinical teams the RN Navigator gathers pertinent clinical and social information to determine the most appropriate service line, level of care, and care setting within the health system, helping to optimize patient flow, resource utilization, and patient-centered outcomes. This is a per diem, hybrid position, consisting of 8-hour day shifts during the week/on weekends. There may be opportunities for remote work.

Requirements

Minimum of 3-5 years of nursing experience, preferably in inpatient care settings.
Experience in an acute care setting and/or provider practice and/or experience in a community-based role or with discharge/transitional planning background 2-3 years required
Bachelor's Degree Nursing required
MA Registered Nurse License required
Basic Life Support [BLS Certification] - Data Conversion - Various Issuers preferred
Strong attention to detail and organization.
Strong cultural awareness competencies.
Proficiency in Microsoft Office.
Maintains good communication skills.
Readily adapts to change and welcomes new approaches when circumstances demand it.

Nice To Haves

Strongly preferred experience in palliative care, oncology, geriatrics, emergency medicine, critical care, or other complex care populations.
Prior experience in nurse navigation, care coordination, case management, or transitions of care strongly preferred.
Demonstrated ability to manage complex patient needs, prioritize referrals, and coordinate care across interdisciplinary teams.
Experience facilitating goals-of-care discussions, discharge planning, and resource coordination preferred.

Responsibilities

In collaboration with the interdisciplinary team, help create a tailored health care plan for assigned patients.
Develop an individualized plan with the MD for appropriate services for the patient.
Reports pertinent observations and reactions regarding clients to the appropriate person (i.e., primary care provider, social worker, or Director).
Assesses and coordinates patients' discharge planning needs with members of the healthcare team.
Resolves patient problems and needs by utilizing multidisciplinary team strategies.
Educates patients regarding how to navigate the health system.