RN Navigator

Mosaic Community Health•Bend, OR

2h•Remote

About The Position

The RN Navigator is a registered nurse who provides clinical navigation and care coordination for patients across Mosaic’s ambulatory continuum. Serving as a consistent point of contact, the RN Navigator utilizes the nursing process to deliver protocol‑driven guidance, risk‑stratified follow‑up, and seamless transitions among primary care, specialty partners, emergency departments, and community services. The RN Navigator role is focused on high-risk patient follow-up and complex care coordination utilizing the nursing process. This role plays a critical part in ensuring seamless communication, timely follow-up, and effective navigation of care for high-risk patients with complex needs. The RN Navigator acts as a resource for urgent and complex referrals, coordinates with both internal and external partners, and supports high-risk laboratory and diagnostic follow-up.

Requirements

Minimum two years of RN clinical experience in acute or ambulatory care preferred.
Care coordination experience in an ambulatory setting preferred.
Experience working with pediatric patients preferred
Associates degree
Current, unrestricted Oregon RN License
BLS/CPR Certification
Valid Oregon State driver’s license
Superior nursing process skills.
Critical thinking and problem-solving skills.
Excellent written, verbal, telephone and interpersonal communication skills.
Familiarity/experience with client interaction on the telephone.
Knowledge of community resources.
Basic typing and computer skills and comfort with Microsoft Windows operating system.

Nice To Haves

Bachelor of Science in Nursing (BSN)
EHR experience - EPIC experience a plus.
Fluency in Spanish preferred.
Involvement with quality improvement processes.
Knowledge of health insurance plans, standard office policies and procedures as well as regulatory requirements including CLIA and OSHA standards.

Responsibilities

Coordinate the care of complex and high-risk patients using evidence-based practice.
Support patient care needs with external partners, to deliver seamless transitions among primary care, specialty providers, and other community services.
Provide and support urgent and complex referral management, facilitating timely and appropriate patient care.
Provide high-risk laboratory and diagnostic follow-up, ensuring prompt action on abnormal results and coordinating necessary interventions.
Perform emergency department (ED) follow-up, contacting patients based on risk stratification to support safe transitions and continuity of care.
Coordinate care needs for patients and/or caregivers in community settings (examples: ALFs, SNFs, foster homes, residential treatment facilities.)
Provide patient and family member education on chronic disease management, acute conditions, and preventive health behaviors.
Utilize standing orders to manage the care of patients.
Perform patient outreach and/or follow-up as directed.
Provide patient care within scope of nursing practice and current competencies, including telephone triage.
Document all interactions in the EHR in a timely, thorough, and accurate manner
Provide Population‑Specific Navigation (as assigned) – adult and pediatrics.
Participate in QI initiatives, track navigator metrics (result turnaround, follow‑up completion, 30‑day ED return rates) and contribute to evidence‑based practice adoption.
Maintain accurate, timely documentation aligned to nursing practice models, policies, and regulatory requirements.