Registered Nurse | Care Continuum Navigator | Part Time

Care Continuum Navigator | Part Time
32 hrs. biweekly, 11am - 730pm, Weekend Option Available

The Care Continuum Navigator (Registered Nurse) plays a vital role in ensuring patients receive coordinated, patient-centered care across the healthcare continuum. Working collaboratively with the Emergency Department (ED), Inpatient Care Management, physicians, primary care providers, post-acute care facilities, and community organizations, this role focuses on improving outcomes for high-risk patients by addressing medical, behavioral, and social determinants of health. 

The Care Continuum Navigator identifies patients with frequent or potentially avoidable emergency department visits and hospitalizations, assesses the underlying causes driving healthcare utilization, and develops individualized care plans that promote health, independence, and appropriate use of healthcare resources. This position serves as a patient advocate and care coordinator, helping patients and their caregivers navigate complex healthcare systems while connecting them with the services and support needed to achieve their health goals. 

Success in this role is measured through improved patient outcomes, reduced avoidable hospital utilization, enhanced care coordination, and achievement of established quality performance metrics. 

Key Responsibilities 

• Collaborate with Emergency Department and Inpatient Care Management teams, physicians, primary care providers, skilled nursing and assisted living facilities, and community agencies to coordinate seamless transitions of care.
• Identify high-risk, rising risk, and Multi-Visit Patients (MVPs) with potentially avoidable emergency department visits or hospital admissions.
• Conduct comprehensive assessments to identify clinical, behavioral, social, and environmental factors contributing to healthcare utilization.
• Develop individualized, patient-centered care plans in partnership with patients, families, caregivers, and interdisciplinary healthcare teams.
• Coordinate care across inpatient, outpatient, post-acute, and community settings to support continuity of care and improve patient outcomes.
• Facilitate discharge planning from the Emergency Department by connecting patients with appropriate follow-up care, community resources, and support services.
• Partner with outpatient care management teams and community organizations to address barriers to care and reduce unnecessary hospital utilization.
• Advocate for patients while promoting safe, effective, and appropriate care in the least restrictive setting.
• Monitor patient progress and evaluate the effectiveness of care coordination interventions using established quality metrics and outcome data.
• Maintain accurate documentation and ensure compliance with organizational policies and regulatory requirements.

Qualifications:

Education - Associates Degree in Nursing required.  Bachelor's of Science in Nursing preferred.

Experience - ASN with a minimum 3 years acute care experience and/or combined relevant experience in acute care Utilization role, SNF, or community health setting, or BSN with at least 2 years of acute care experience and/or combined relevant experience in acute care, utilization role, SNF, or community health setting.

Licensure/Certification - Current license to practice as Registered Nurse in the State of Maryland, or if resident of a state that participates in Nurse Multi-State Compact agreement, holds Registered Nurse License from that state that is designated as "Compact" or "Multi-State Privilege" using primary source verification and provides additional documentation as required by the Maryland Board of Nursing.  RN License from a compact state with a designation of "Single State" does not meet the requirement and nurse must obtain a Maryland license. Care/case management certification required in 5 years of employment from an accrediting body.

Knowledge/Skills/Abilities - Knowledge of care management principles, professional practice standards, and health and public policy. Excellent clinical, interpersonal, and communication skills. Must be able to work collaboratively with other healthcare professionals as well as independently. Experience with coaching while working with the chronic, complex population. Must have knowledge of evidenced based practices, in depth knowledge of disease processes, and knowledge of community res