Job Description

Job Description

ChristianaCare is currently seeking a full-time outpatient Nurse Navigator for our Supportive and Palliative Care practice in Newark, DE.

Work Schedule

• Monday-Friday, day shift
• No weekends or holidays required

Principal Duties and Responsibilities

Coordination of Care

• Assists Palliative Care staff with coordinating referrals from within and outside of Christiana Health Care.
• Completes a review of the patient upon initial encounter and periodically throughout navigation, matching unmet needs with appropriate services.
• Assists with identifying potential and realized barriers to care (e.g., transportation, caregiver support, housing, language, culture, literacy, role disparity, psychosocial, employment, financial, insurance) and facilitates referrals.
• Schedules and/or facilitates scheduling of appointments.
• Triage of family/caregiver phone calls, messages determining disposition of call. Coordinates response with Palliative clinicians based on clinical assessment and communicates treatment plan/recommendations to patient/caregiver.
• Organize inpatient palliative census and daily workload. Evaluate and triage consults by collaboration with the hospital team (bedside nurse, consulting providers).
• Support established inpatients in lieu of Palliative provider consult.
• Collaborates with the outpatient team for seamless transition.
• Provides psychosocial support to and facilitates appropriate referrals for patients, families, and caregivers, especially during periods of high emotional stress and anxiety.
• Supports discussions with patients and caregivers related to goals of care and end of life treatment decisions (hospice). Facilitates scheduling of family/provider meetings.
• Applies basic knowledge of insurance process (e.g., Medicare, Medicaid, third-party payers) and their impact on staging, referrals, and patient care decision toward establishing appropriate referrals, as needed.
• Monitors progress in achieving defined patient specific, clinical outcomes through performance improvement activities and outcomes.
• Manages care flow and navigates multidisciplinary treatment needs (including communication with and coordination of tests, and imaging).

Education

• Assesses patient and family learning needs to identify barriers to education (e.g., literacy, language, cultural influences, comorbidities)
• Utilizes “Teach Back method for patient education.
• Collaborates with multidisciplinary team to develop patients’ clinical treatment plan.
• Educates the patient/family/caregiver: diagnosis, treatment options, medication side-effect management, behavioral disturbance triage and guidance.
• Assists patient/family with appropriate information to make an informed decision.
• Maintain our inpatient patient education resources – (booklets on end-of-life expectations, pamphlets on our team and resources)
• Provide system education to nurses on nursing role in palliative care (by helping inpatient nurses understand how to interact with hospice, and be a nurse providing comfort care and advocating for basic primary palliative care for their patients)

Communication

• Facilitates communication among the Palliative Care team to prevent fragmented or delayed care.

• Acts as a liaison and advocate between the patients, families, caregivers, and health care providers to promote and optimize patient outcomes.
• Empowers patients and families through education and encouragement to self-advocate and communicate their needs.
• Adheres to established regulations concerning patient information and privacy.

Professional Role

• Contributes to Palliative Care program development, implementation, and evaluation within the healthcare system and community.
• Maintains required credentials and participates in learning to stay current with disease specific information and issues related to memory care, insurance, ethical issues.
• Contributes to the knowledge base of the healthcare community and in support of the Palliative Care role through activities such as involvement in professional organizations, presentations, publications, and research.
• Participates in system committees such as magnet, nursing council, safety, cultural competency/diversity, patient education, professional nursing council.
• Is a Mentor for students and other members of the team.

• Works with health improvement team to implement and evaluate new processes of care and patient flow which are determined by the team utilizing pathways, guidelines, and algorithms.
• Supports a culture of safety, respect, and commitment to excellence and inclusivity.

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Education and Experience Requirements

• BSN required.
• Masters in nursing preferred.
• RN license or eligible for licensure in the state of Delaware, Pennsylvania, New Jersey, or Maryland
• Three or more years of combined clinical experience in clinical and/or administrative experience in case management, clinical trials, older adult, palliative/hospice care preferred.
• Nursing Cert - Certified Hospice and Palliative Nurse (CHPN) - Hospice & Palliative Credentialing Center within 3 years of hire.

Special Requirements

• RN license or eligible for licensure in the state of Delaware.
• BLS

Qualified candidates should apply online and include a current resume.

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