RN, Nurse Navigator
About The Position
The nurse navigator is a specialized hospital-based registered nurse who coordinates customized, age-friendly care for complex geriatric surgical patients, typically age 65 and older. The role supports patients before surgery, during their hospital recovery, and through safe, coordinated transitions out of the hospital. The navigator serves as a central communication point among inpatient and outpatient teams and helps ensure completion of the Geriatric Surgery Verification (GSV) program components. The position provides individualized assistance and comprehensive care coordination for patients and their families or caregivers throughout the surgical journey, from preoperative preparation and screening through the perioperative period, discharge, and postoperative follow-up. The navigator assesses and stratifies clinical risks and needs, works to remove barriers to timely care, facilitates communication with care teams, and serves as a contact for patients, families, and providers. The role collaborates with surgical teams, the Centers for Perioperative Medicine, hospitalists, specialists, nursing teams, and social workers.
Requirements
- Bachelor's degree in Nursing (BSN) and 3 years of clinical nursing experience, or an equivalent combination of education and experience.
- At least 1–2 years in an acute-care setting such as Med-Surg, ICU, or ED is strongly preferred.
- Registered Nurse (RN) state licensure and/or compact state licensure upon hire is required.
- Competence in critical thinking, interpersonal relationships, and technical skills is required.
- An associate-degree RN must complete a BSN within 5 years.
- Strongly preferred: understanding of geriatric syndromes, chronic disease processes, and polypharmacy management.
- Strongly preferred: exceptional communication and active-listening skills, including empathetic communication with older adults and stressed family caregivers and communication with interdisciplinary specialties and professionals.
- Strongly preferred: proactive, self-directed, motivated, and organized, with the ability to work autonomously in a fast-paced environment.
- Strongly preferred: proficiency with Electronic Health Records (EHR) systems, documentation, and Microsoft Office.
- Strongly preferred: contributions to quality improvement, performance excellence, or unit performance initiatives.
- Strongly preferred: contributions to identifying and developing goals and workflows to improve outcomes for patients and families.
Nice To Haves
- Previous nurse navigator, care coordination, case management, or utilization experience, with a strong background in geriatrics, home health, or palliative care.
- Certified Case Manager (CCM), Board Certification in Gerontological Nursing (RN-BC), or an equivalent navigation certification is encouraged.
- Certification in a nursing specialty area upon hire is preferred.
- At least 1–2 years of acute-care experience in Med-Surg, ICU, or ED is strongly preferred.
Responsibilities
- Assist with preoperative phone screens to ensure elective surgery patients are screened for frailty.
- Arrange timely referrals and appointments at the Centers for Perioperative Medicine for frail preoperative patients, and ensure appropriate communication with inpatient co-management teams, surgical teams, and primary care physicians.
- Identify high-risk geriatric patients upon admission or in the Emergency Department and assess cognition, delirium risk, functional status, fall risk, and polypharmacy.
- Develop relationships with patients, families, and caregivers from diagnosis through the initiation and completion of active treatment.
- Maintain collaborative relationships with families and caregivers, multidisciplinary providers, nursing leadership and staff, and internal service departments.
- Facilitate communication among multidisciplinary team members and support care-team handoffs for transitions between care settings.
- Provide ongoing support and serve as a resource for patients and families during treatment and after discharge; identify needs and coordinate how and when care is delivered.
- Participate in implementing and evaluating age-friendly policies and procedures, assessing practice patterns and compliance barriers, and developing and implementing improvement plans as needed.
- Provide community education on age-friendly care, including advance directives, shared decision-making, and maintaining function.
- Develop and participate in patient, family, and staff education, and develop and update written patient education materials.
- Participate in high-risk conferences, organize meetings and patient rosters, and distribute meeting minutes and feedback to participants and teams.
- Perform other duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
