Nurse Navigator - Senior Health

Number of Job Openings Available:

1

Date Posted:

June 03, 2025

Department:

78007328 Senior Care Transitions Complex Care

Shift:

Day (United States of America)

Shift Length:

8 hour shift

Hours Per Week:

40

Union Contract:

Non-Union-NCT

Weekend Rotation:

None

Job Summary:

Independently coordinates complex panel of Senior Health participants while ensuring an interdisciplinary approach with care team providers that results in an integrated person-centered plan of care. This collaborative care plan is designed to advocate and assist participants in coping with complex health issues and enhance the person’s ability to function and access appropriate services.

Provides clinical consultation as needed to medical providers, pharmacists, non clinical staff, clinical staff and other team members as appropriate.

Key Position Details:

• 40 hours per week
• Hybrid role - includes community/in-home visits with patients.
• Monday - Friday, 8:30am - 4:30pm
• No weekends

Territory includes: S Minneapolis, Saint Paul, Apple Valley, Bloomington, Burnsville, Lakeville, Eagan, Farmington, Lillydale, Mendota, Mendota Hts., Rosemount, Sunish Lake & West St. Paul

Job Description:

Principle Responsibilities

• Conducts Comprehensive Assessment.
  • Gathers all relevant data and information by communicating with the participant, family, healthcare provider, other members of the healthcare delivery team and community support network including external healthcare providers and agencies.
  • Completes a medication review with attention to eliminating barriers to medication adherence.
  • Uses clinical expertise and established criteria to identify risk factors and determine recommendations to mitigate adverse health outcomes.
  • Evaluates data identifying strengths and barriers including social determinants impacting health and chronic or acute problems or conditions impacting function and quality of life.
• Develops Plan.
  • Develops a person centered care plan that focuses on enhancing strengths to support health and well being.
  • Builds trust with participant to encourage full engagement in care planning process and implementation.
  • Communicates care plan to participant, health care provider and community supports to ensure most effective implementation.
  • Supports planning across the continuum of care in collaboration with other health care providers, specialty and community providers to facilitate transitions of care.
  • Supports planning with community resources and external healthcare agencies to provide broadest available integrated network of support as needs indicate.
  • Maintains high level oversight of the integrated plan to assure goals are met and addressed.
• Facilitates Implementation of Plan.
  • Maintains contact with participant and relevant circle of support as required/needed to promote best health outcomes.
  • Works with participant, family and providers to resolve identified barriers.
  • Works with participant, family, healthcare providers and community supports to coordinate needed services.
  • Utilizes motivational interviewing skills to facilitate and engage participants towards behavioral changes through exploration and resolving ambivalence.
  • Facilitates communication between participant, family and all members of the health care team.
  • Facilitates referrals for participants as appropriate.
  • Administers health care benefits and coordinates care within the benefit set.
  • Identifies alternate sources of funding if available for services as indicated.
  • Assists participants to navigate health care system and access appropriate services and resources.
  • Addresses complex communication and planning issues as participant receives services across the continuum (in particular for patients with multiple specialists and services).
  • Leads and supports transition and discharge planning for participants moving between levels of care.
• Monitors Progress Toward Goals.
  • Initiates care plan modifications as necessary through monitoring and evaluation to accommodate changes and encourage optimal health and safety over time.
  • Follows the participant over time, across continuum of care to measure effectiveness of the plan.
  • Adapts plan to meet changing needs.
  • Communicates with participant, family and healthcare providers about changes in plan.
  • Documents all encounters thoroughly in timely manner in designated data system.
• Provides qualified professional oversight as needed to ensure appropriate care plan development.
  • Participates in work groups and committees as appropriate
  • Supervises and d