Nurse Navigator, Neurology

We are so glad you are interested in joining Sutter Health! 

Organization:

SPMF-Sutter Pacific Medical Foundation - South

Position Overview:

A professional registered nurse (RN) who offers individualized assistance to patients, families and caregivers to help overcome health care system barriers. Enhances the patient experience and improves the clinical outcome for patients by providing a seamless navigation process throughout the continuum of care. Responsible for collaborating with physicians and members of the interdisciplinary teams to triage, coordinate, and consistently manage patient care by educating the patient and serving as a point of contact for patients and families. Participates in strategic initiatives within the clinical program or service line to include developing, implementing and monitoring navigation activities and sustainability, facilitates shared decision making and patient engagement by forming trusting relationships and addressing patients' communication and health literacy needs, while helping them integrate their values and preferences into treatment decisions. Works for and promotes positive outcomes for patients, providers and the Sutter health care system.

Job Description:

These Principal Accountabilities, Requirements and Qualifications are not exhaustive, but are merely the most descriptive of the current job. Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job change (for example, emergencies, staff changes, workload, or technical development).

JOB ACCOUNTABILITIES:

Coordinates patient care through the point(s) of continuum specified by assisting with timely access to care, coordinating/facilitating appointments and services, and accompanying patients to appointments as needed.
• Facilitates timely coordination of appointments/services
• Meets with patient by phone or in person “within designated time” following “designated event” and follows patient per facility-specific guidelines
• May include meeting with the patient in both acute and non-acute Sutter Health locations. Coordinates appointments, if applicable, for diagnostic testing, services, and with providers to ensure timely delivery of diagnostic and treatment services. May include accompanying patients to appointments (particularly if there are multiple barriers to care) and/or, providing clarification and literacy-level appropriate education related to the visit.
• Provides care coordination, symptom management support, guidance, education and advocacy across care settings.
• Discusses physician visits with patients and families and answers questions
• Provides and reinforces education re: treatment, care plan, symptom management, and survivorship concerns
• Facilitates shared decision making and patient engagement by forming trusting relationships and addressing patients’ communication and health literacy needs, while helping them integrate their values and preferences into treatment decisions.
• Empowers patients with education and knowledge to help improve patient outcomes and satisfaction

Assesses patients’ current and future needs, provides patient access to resources (internal and external), facilitates patient needs assessments, including distress screenings and acuity scales; coordinates/facilitates appropriate referrals.
• Assesses for and identifies patient/family needs and matches unmet needs to appropriate resources during care continuum, based on clinical guidelines and evidence based practices.
• Assesses for and works to mitigate barriers to care. Assists patients with access concerns (for screening, diagnosis, and/or treatment, as appropriate) and assists with paperwork as needed
• Makes referrals for services based on patient/family needs—i.e., education, finances, psychosocial, survivorship, transportation, child care, lodging.
• Facilitates access to physicians and services.
• Facilitates appropriate medical record availability at scheduled appointments as needed. vi. Facilitates language translation or interpretation services. vii. Facilitates financial assessment and referrals along with assisting with completing forms as needed.
• Facilitates linkages to follow-up services
• As appropriate, facilitates screening for and access to clinical trials, molecular testing and/or genetic counseling. Builds partnerships with local agencies and groups (e.g., referrals to other services and/or support groups)
• Facilitates distress and acuity screening and makes appropriate referrals


Establishes and maintains close collaboration with providers and care team to communicate effectively ensuring seamless patient care and care coordination.
• Communicates and collaborates with invol