Nurse Navigator

Muckleshoot Indian Tribe•Auburn, WA

4h•$94,034 - $150,458•Onsite

About The Position

The Nurse Navigator provides nursing care coordination, transitional care, disease management, patient education, and advocacy for patients with complex healthcare needs. The position supports patients during hospitalization and discharge, emphasizing continuity of care among hospitals, the Muckleshoot Health and Wellness Center (MHWC), specialty providers, and other healthcare and community services. The Nurse Navigator works with patients, families, MHWC providers, the Social Worker, hospital care teams, and outside organizations to identify barriers, coordinate services, and support successful transitions after hospitalization. This is an onsite, Monday-Friday role. The role includes coordinating care for hospitalized patients and those transitioning from inpatient care, communicating significant changes in status and anticipated discharge needs, reviewing discharge plans, identifying transition barriers, and conducting post-discharge follow-up. The Nurse Navigator performs medication reconciliation, reviews instructions and follow-up plans, monitors clinical concerns, coordinates appointments and resources, and provides patient and family education. The position also supports chronic disease management in the clinic and cross-covers other nurses when needed. The Nurse Navigator collaborates with the Social Worker and healthcare team to address psychosocial needs and social determinants of health, makes appropriate referrals, and advocates for coordinated, patient-centered care. Care must be culturally responsive and respectful of Tribal values, traditions, family involvement, and patient preferences. The role requires timely and accurate electronic health record documentation and compliance with applicable laws, clinical standards, organizational policies, and privacy requirements. Work is performed mostly in a clinic setting, with visits to hospitalized patients as needed.

Requirements

Graduation from an accredited Registered Nursing program.
Two years of hospital clinical experience.
Washington State RN license.
Washington State driver's license.
Skills in phlebotomy and physical assessment.
Oral and written communication, problem solving, patient interviewing, time management, crisis intervention, and initiating appropriate emergency responses.
Ability to establish and maintain working relationships and work with diverse populations and cultures.
Ability to handle several tasks simultaneously and read and follow written medical orders.
Ability to communicate effectively with patients, families, healthcare professionals, and outside organizations.
Ability to establish trusting, professional, and culturally respectful relationships with patients and families.
Ability to work independently, organize and prioritize multiple patient needs, manage time, and adapt to changing clinical situations.
Ability to work collaboratively as part of a healthcare team.
Ability to use electronic health record systems and other technology for care coordination and communication.
Knowledge of professional nursing principles, practices, and standards; transitional care; hospital discharge processes; chronic disease management; care coordination; medication reconciliation; and post-discharge nursing assessment and follow-up.
Knowledge of medical terminology, anatomy, physiology, pathophysiology, basic pharmacology, medical record documentation, and basic laboratory procedures.
Knowledge of equipment, supplies, and materials used for medical treatment; healthcare system structure and function; infectious disease management, control, and safety standards; and human wellness, illness, growth and development, nutrition, behavioral, psychosocial, and family systems.

Responsibilities

Coordinate care for MHWC patients who are hospitalized, transitioning from inpatient care, or have complex medical and disease-management needs.
Communicate hospitalizations, significant changes in patient status, care coordination needs, and anticipated discharge needs to the patient's MHWC primary care provider and appropriate care team members.
Facilitate the exchange of relevant clinical information among hospitals, MHWC providers, specialists, pharmacies, and other healthcare organizations.
Review hospital discharge plans with the Social Worker and identify barriers that could affect a safe transition home, including medical, medication, equipment, transportation, social, and behavioral barriers.
Conduct timely post-discharge follow-up by telephone, in-person visits, or other appropriate methods.
Perform medication reconciliation and review discharge instructions, treatment plans, referrals, laboratory testing, imaging, and other recommended follow-up care.
Monitor clinical alerts, changes in patient condition, and other health concerns, and communicate or escalate concerns in accordance with clinical protocols and scope of practice.
Coordinate primary care, specialty care, and other healthcare appointments; assist with reminders and preparation; and help arrange transportation or other resources when needed.
Provide individualized patient and family education regarding diagnoses, medications, treatment plans, warning signs, follow-up recommendations, and chronic disease management.
Collaborate with the Social Worker to identify and address psychosocial concerns and social determinants of health.
Screen for patient distress and psychosocial needs and facilitate referrals to behavioral health, social services, community resources, transportation, and other services.
Advocate and act as a liaison among patients, families, MHWC, hospitals, specialists, and outside organizations to promote coordinated, patient-centered care.
Provide culturally responsive nursing care that respects Tribal values, traditions, family involvement, patient preferences, and community needs.
Maintain accurate and timely electronic health record documentation of assessments, communication, coordination, education, interventions, referrals, follow-up, and outcomes.
Participate in clinic nursing activities and chronic disease management programs, and cross-cover other nurses when needed.
Follow applicable laws, regulations, clinical standards, organizational policies, and procedures.
Protect the privacy and confidentiality of protected health information.
Perform other office and field duties as needed in support of the Tribe's community service and member well-being.