Population Health Nurse Navigator Full Time (80 hours per pay period)

Bronson Healthcare•Kalamazoo, MI

1d•Onsite

About The Position

The Nurse Navigator guides patients through the health care system, establishing contact with newly diagnosed patients as early as possible and coordinating services with physicians, specialists, ancillary services, other health care facilities, and community resources. The role provides patients and families with psychosocial support, resource access, and education about diseases and treatment options. Depending on the service line, the Navigator also supports clinical pathways, evaluates outcomes and quality improvement, and coordinates care for patients in bundled payment programs. The Population Health Nurse Navigator supports Care at Home Advanced Practice Providers (APPs) delivering longitudinal in-home primary and palliative care to high-risk patients. The role uses analytics-driven outreach to identify and engage appropriate patients, conducts telephone triage, manages APP schedules, handles referrals and patient communications, and makes follow-up calls after hospital or skilled nursing facility transitions to help prevent avoidable readmissions. The Navigator coordinates post-acute care, community resources, and plans of care with palliative care and post-acute teams, supporting value-based care and population health goals. Other service-line duties described include guiding patients with heart failure through education and transitions of care, supporting patients and families facing serious or life-limiting illnesses, and helping patients prepare for elective surgery through referrals and health-status optimization. The role may participate in multidisciplinary rounds, maintain program databases, track outcomes and satisfaction, and represent programs in the community. Travel is required to serve Kalamazoo and Calhoun County. The position requires rotating weekend and holiday coverage for the Heart Failure Nurse Navigator assignment.

Requirements

Bachelor's degree in nursing.
Five years of professional nursing experience in the specific service line or a related area.
Current Registered Nurse license in good standing with the State of Michigan.
BLS certification within six months of hire.
Evidence of successful completion, or an approved audit, of a CPR training course within the past two years, or successful completion of a CPR course or approved audit within six months of hire.
Clinical expertise in care management, transitions of care, and telephone assessment for the Population Health Nurse Navigator role.
Clinical expertise in heart failure and chronic disease management for the Heart Failure Nurse Navigator role.
Oncology Nursing Certification within three years of hire for the Cancer Care Center only.
For the BBC Cancer Center: preferred eligible candidates must have a BSN; alternative eligible candidates may have an ASN and seven years of oncology experience, with agreement to obtain a BSN within three years.

Nice To Haves

Master's degree in nursing.
For the BBC Cancer Center, an ASN with seven years of oncology experience is an alternative eligibility route, provided the candidate agrees to obtain a BSN within three years.

Responsibilities

Guide patients through the health care system and establish contact with newly diagnosed patients as early as possible.
Coordinate care and act as a liaison among patients, families, physicians, specialists, ancillary services, other health care facilities, and community resources.
Provide psychosocial support, connect patients with resources, and educate them about disease specifics and treatment options.
Support the development and maintenance of clinical pathways and measure patient outcomes.
Coordinate care for applicable service-line patients in bundled payment programs, and evaluate program quality and outcomes.
Use analytics-driven outreach to identify and engage high-risk, high-utilization patients appropriate for home-based services.
Conduct telephone triage to assess patient needs and determine whether an APP home visit or another disposition is appropriate.
Manage APP schedules and serve as the single point of contact for incoming referrals and patient communications.
Complete follow-up calls after hospital and skilled nursing facility transitions to support continuity of care and help prevent avoidable readmissions.
Coordinate post-acute processes, community resources, and plans of care with APPs, palliative care teams, and SNF/post-acute care managers.
For heart failure patients, provide education about medication adherence, fluid management, and early signs of worsening symptoms; reinforce discharge instructions and coordinate post-discharge needs.
For patients with serious or life-limiting illnesses, facilitate access to palliative and supportive care, support care aligned with patient goals and values, and coordinate care across settings.
Identify high-risk patients before elective surgery and facilitate optimization of health status, including referrals for comorbidities, weight management, or smoking cessation.
Participate in multidisciplinary rounds and conferences and serve as a resource to clinicians and case managers.
Engage patients and families in value-based programs and explain episode care plans, resources, support programs, and services.
Maintain required patient and program databases, enter data, and track volumes, clinical outcomes, and patient satisfaction.
Represent programs in the community, including through public speaking and related activities.
Develop action plans that support program initiatives and budget goals, and monitor budget adherence and resource use.
Travel to serve Kalamazoo and Calhoun County.
Provide rotating weekend and holiday coverage for the Heart Failure Nurse Navigator assignment.