Nurse Navigator, Hospital at Home
About The Position
The Hospital at Home Nurse Navigator provides discharge planning, care coordination, and follow-up care for patients in UChicago Medicine’s Acute Hospital Care at Home model. The role advocates for patients and uses clinical judgment to coordinate timely, individualized care that supports positive outcomes during the acute stay and after discharge. The Nurse Navigator explains and teaches patients and caregivers about the model’s care plans, technologies, and processes, and follows applicable National Patient Safety Goals. The position manages an ongoing caseload and coordinates with multidisciplinary teams to support transitions into and out of the home setting. It includes protocol-driven patient assessment and interventions, clinical health coaching, identifying community support needs and social barriers, monitoring biometric data, conducting audio/visual visits, facilitating admissions, and completing transition-of-care outreach and documentation. The Nurse Navigator follows clinical protocols, supports evidence-based practice and research, contributes to process improvement and a culture of safety, and must be comfortable adopting new technologies and explaining them to patients. This is a full-time, onsite position at Hyde Park, assigned to the Hospital at Home unit. The shift is days, Monday through Sunday.
Requirements
- Associate degree required.
- Five years of Registered Nurse experience in an acute care setting.
- Current Illinois RN license.
- Current BLS certification upon hire, or completion within 30 days of hire.
- Ability to communicate effectively in English.
- Demonstration of core competencies within 90 days.
- Completion of all position-specific and unit-specific competencies within 12 months.
- Ability to adopt new technologies and clearly explain their use to patients.
Responsibilities
- Manage a designated caseload and respond to rapidly changing priorities.
- Collaborate with multidisciplinary teams to support successful transitions to the home setting and discharge from the Hospital at Home model.
- Plan and facilitate clinical health coaching to support patients’ self-management of acute and chronic conditions and lifestyle changes.
- Identify patients who need community support and coordinate assistance addressing social determinants of health.
- Communicate critical elements of the care and transition plans to physicians, the multidisciplinary team, patients, and families, and expedite teaching needs.
- Navigate patients and families across the phases of UChicago Medicine’s Hospital at Home model.
- Monitor biometric data and escalate findings according to Hospital at Home protocols.
- Conduct audio/visual patient care visits as directed by the care team or protocol.
- Ensure care-plan interventions are implemented efficiently using a patient-centered approach.
- Use UChicago Medicine and supplier-partner resources to support collaborative workflows, standards, policies, protocols, guidelines, and documentation systems for safe, high-quality, evidence-based care.
- Follow clinical protocols and complete necessary training to provide evidence-based care.
- Promote professional practice and a culture of safety, and participate in process-improvement efforts.
- Complete transition-of-care outreach, documentation, and follow-up care.
- Provide protocol-driven assessment, care coordination, and interventions for diverse patient populations.
- Use sound clinical decision-making and critical-thinking skills, and practice according to nursing guidelines and state and hospital regulations.
- Facilitate admissions to Hospital at Home according to UChicago Medicine guidelines.
- Use nursing knowledge to identify, prevent, and address complex acute or recurring patient-care problems.
- Share expertise with the multidisciplinary team and serve as a resource to staff in areas of expertise.
- Support research to advance knowledge and evidence-based practice.
- Perform other assigned duties and maintain accurate records using multiple databases and IT resources.
- Maintain an ongoing caseload for regular outreach and management.
- Explain the model’s care plans, technologies, and processes to patients and caregivers.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
