RN, Chronic Care Navigator (non Exempt)

Chronic Care Nurse Navigator

The Chronic Care Nurse Navigator plays a pivotal role in coordinating comprehensive care for patients with chronic conditions. This individual will serve as a central point of contact, guiding patients and their families through the healthcare system, ensuring timely access to services, and promoting adherence to treatment plans. The Nurse Navigator will also educate patients on self-management strategies and connect them with community resources.

Patient Advocacy and Education:

• Act as a patient advocate, ensuring their needs and preferences are addressed throughout their care journey.
• Provide education to patients and families regarding their chronic conditions, treatment plans, medication management, and lifestyle modifications.
• Empower patients to participate in their care decisions and develop self-management skills actively.

Care Coordination and Navigation:

• Assess patient needs and develop individualized care plans in collaboration with the healthcare team including primary care providers, clinic patient navigator, case management team, and clinic office staff.
• Coordinate appointments, diagnostic tests, and specialist referrals.
• Facilitate communication between patients, families, and all members of the healthcare team.
• Identify and address barriers to care, such as transportation, financial constraints, or lack of social support, and work in conjunction with the patient navigator/navigation team.
• Monitor patient progress and make adjustments to care plans as needed.
• Oversight of the clinic patient navigator to ensure that patients needing primary care and specialty care are captured and referred as needed.

Resource Management:

• Connect patients with relevant community resources, support groups, and educational materials.
• Maintain an up-to-date knowledge of available resources and services.