Nurse Navigator

UMass Memorial Health•Leominster, MA

23h•$78,874 - $141,981•Onsite

About The Position

At UMass Memorial Health, everyone is a caregiver – regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day. Guides patients through the healthcare system from screening through diagnosis and follow up, by assisting with access issues, developing relationships with service providers and tracking interventions and outcomes. Promotes a positive work environment which emphasizes respect to our customers, patients, patients’ families, providers, caregivers, and other departments. Serves as a clinical expert in the care of these patients.

Requirements

Bachelor’s degree in Nursing.
Current Massachusetts Registered Nurse licensure and registration.
Minimum of 5 years nursing experience.
Excellent teaching, consultation, and customer service skills.
Excellent critical thinking skills.
Demonstrates leadership experience.
Excellent verbal and written communications skills.
Computer literate with knowledge of Microsoft Office products.
Minimum one year experience in surgical/procedural service line (eg. IR, vascular surgery).
Must have a minimum of eight hours of education per year on cerebrovascular disease and stroke.
Must obtain NIHSS and mRS certification within one month after start date.
Must obtain SCRN certification within 18 months after start date.
Experience working with patients with COPD and asthma diagnoses, educating them in disease management, self-education in medication management and lifestyle changes.
Experience helping patients navigate the health care system in managing anxiety and depression related to chronic pulmonary disease.
Experience working with Medicare or attributed PCF / UMMACO beneficiaries with a mix of behavioral health conditions and multiple chronic conditions, assisting with medication review and reconciliation as they transition from one care setting to the next, educating them in disease management, self-education in medication management, recommending referrals to SUD/OUD addiction coaching or bridging clinic as needed
Experience helping patients navigate the health care system to obtain appropriate behavioral health services, psychiatric consults, access to therapy, guidance in managing anxiety and depression related to chronic disease (e.g. CHF, CKD), provide guidance in end-of-life care, recommend referrals to palliative care and hospice based on eligibility and suitability
Minimum of 3 years of Cardiology RN experience.
Ability to work in a strong team environment.
Excellent assessment and documentation skills. Proficient and accurate in documentation.

Nice To Haves

Masters Degree in Nursing.
Skilled with utilization of EMR and other software.
Experience with Project Management.
Breast Nurse Navigators require accreditation through NAPBC.
Oncology Certification preferred unless a Breast Nurse Navigator.
Minimum of 5 years oncology experience in specific disease site (breast, lung, GI, etc) and post-surgical nursing.
Palliative Care Certification.
Previous Palliative Care experience.
2 years of previous Orthopedic care experience.
Previous experience with risk-based episodes of care.
2 years of previous Endoscopy care experience.
Certification in Neurosciences.
Ambulatory Nurse or other ANCC certification.
Experience in acute care and/or other Neurological disease specific conditions.
Experience triaging patients with pulmonary exacerbations (across post-acute care settings) with PCPs and pulmonologists to avoid ED visits and hospitalizations or readmissions.
Familiarity with Better Breathers Clubs to support COPD patients post discharge from hospital or post-acute SNF or inpatient rehab facility to help with ongoing education and emotional support in the community. Familiarity with smoking cessation programs and group support options, net-working opportunities for patients living with chronic lung disease.
Familiarity helping adults better manage their asthma by using programs such as Breathe Well, Live Well: The Guide to Managing Asthma at Home and Work as a tool to educate and empower patients to take control of their asthma.
Experience triaging patients with multiple BH / SUD and medical co-morbidities across acute and post-acute care settings with PCPs and specialists (e.g. cardiologists, nephrologists, endocrinologists, urologists, neurologists, psychiatrists, therapists) to avoid ED visits and hospitalizations or readmissions
Provides education, information, and referral to specialized intervention programs, including but not limited to substance abuse detoxification, psychiatry consults, cardiac and pulmonary rehabilitation and wellness and prevention services. Advocates and works to resolve problems of patient access to these services. Follows up with patients to complete and evaluate social service referrals, working with medical and mental health providers as well as community service agencies to develop alternate plans when indicated
Establishes and maintains effective working relationships with community resources and agencies (HHAs, Hospices, community-based palliative care programs, mental health clinics, other CBOs) through telephone, electronic and/or direct contact.
Experience in community settings treating TB, HIV, or Sexual Transmitted infections.
Previous experience in a Nurse Navigator position.
Previous clinical experience in Oncology.
Knowledge of radiology/radiation safety.
Previous experience with Epic.
Radiology background.
Experience with Breast Imaging or Breast Oncology Care.

Responsibilities

Facilitates the entry of patients into the diagnostic and/or treatment system and coordinates their care including family involvement. Follows the patients throughout the continuum of health care services across multiple departments.
Assists patients in understanding their diagnosis, treatment options, recommended follow up and resources available.
Utilizes nursing process to comprehensively assess the patients’ physical and psychological sta-tus.
Evaluates progress of patients along the continuum and is responsible for professional and per-sonal modifications along with the healthcare team as appropriate. May assist with tracking of post care patients to ensure post treatment standards of care are met along with referrals. As necessary, ensures that patients receive clinical satisfaction surveys.
Coordinates and participates in multidisciplinary planning conferences, collaboratively assists with the development of patient summaries for use by care team.
Provides patient and family education across the continuum of care and facilitates symptom management.
Provides access to community resources and links to support services such as: social services, nutrition services, psychologist, pastoral care, physical therapy, rehabilitation therapy, financial counseling, pharmacy, and related organizations. May coordinate and participate in patient support groups with Social Workers.
Assists with tracking metrics and quality indicators for diagnosing and treating promptly and ef-fectively. May assist with production of relevant quality improvement reports.
Develop, implement, support and/or attend related programs/workshops/seminars/support services, etc.
Utilization and optimization of data systems to identify and triage patients and track data out-comes.
May assist with calls to Clinic and perform telephone triage within the scope of practice as a li-censed registered nurse.
May work across multiple campuses and settings.
Complies with established departmental policies, procedures, and objectives.
Attends variety of meetings, conferences, seminars as required or directed.
Demonstrates use of Quality Improvement in daily operations.
Complies with all health and safety regulations and requirements.
Respects diverse views and approaches, demonstrates Standards of Respect, and contributes to creating and maintaining an environment of professionalism, tolerance, civility and acceptance toward all employees, patients, and visitors.
Maintains, regular, reliable, and predictable attendance.
Performs other similar and related duties as required or directed.