Nurse Care Navigator, RN

Job title

Nurse Care Navigator (RN)

Reports to: Nurse Coordinator

Status: Non-Exempt (Hourly $34.00 - $44.00)

Job Purpose

The Nurse Care Navigator provides clinical triage and care coordination support to Family Medicine, promoting timely access to care, continuity of services, patient engagement, and positive health outcomes. This role serves as a clinical resource for patients and the Family Medicine care team by assessing patient concerns, coordinating follow-up, supporting transitions of care, and helping patients navigate recommended services.

The Nurse Care Navigator works collaboratively with providers, RNs, licensed practical nurses (LPNs), certified medical assistants (CMAs), patient service representatives, pharmacy, behavioral health, and other members of the interdisciplinary care team. The role supports the timely assessment and escalation of clinical concerns, completion of recommended care, and coordination of services for patients with complex needs or identified barriers to care.

The Nurse Care Navigator supports proactive, population-based care through patient outreach, preventive care coordination, chronic disease management, and closure of identified care gaps. The position contributes to Heartland Community Health Center’s quality improvement and value-based care strategies by helping ensure patients receive appropriate care at the right time and that identified needs are addressed and documented.

The Nurse Care Navigator advances Heartland’s mission to welcome all who need care by providing compassionate clinical support, strengthening care team collaboration, and helping patients access the services and resources they need to improve their health.

Duties & Responsibilities

Clinical Triage and Patient Support

• Provides telephone, electronic, and in-person clinical triage for Family Medicine patients using established protocols, evidence-based guidelines, and sound nursing judgment.
• Assesses patient symptoms, health concerns, relevant medical history, and clinical information to determine the appropriate level and urgency of care.
• Identifies clinical concerns requiring provider consultation, same-day appointments, urgent evaluation, emergency services, or other appropriate interventions.
• Coordinates with Family Medicine providers and the care team to ensure timely responses to patient questions, symptoms, and clinical concerns.
• Provides nursing guidance, patient education, and self-care recommendations within the RN’s scope of practice and established protocols.
• Evaluates patient concerns and escalates changes in condition or potential safety risks through established clinical pathways.
• Documents assessments, clinical decisions, interventions, communications, and follow-up plans accurately and promptly in the electronic health record.
• Supports consistent use of triage protocols, escalation pathways, and documentation standards across Family Medicine.
• Identifies recurring triage needs, access barriers, and workflow challenges and collaborates with the care team to improve patient response and service delivery.

Patient Care Coordination and Navigation

• Coordinates care for patients requiring additional follow-up, assistance navigating services, or support managing multiple healthcare needs.
• Tracks outstanding patient care needs and coordinates with appropriate team members to support completion of recommended services.
• Supports transitions of care following emergency department visits, hospitalizations, and other significant healthcare encounters.
• Conducts or coordinates timely post-discharge outreach, including assessment of unresolved concerns, review of follow-up needs, and coordination of recommended appointments.
• Supports medication-related care coordination by identifying access barriers, adherence concerns, medication questions, and needs requiring provider or pharmacist follow-up.
• Collaborates with pharmacy, behavioral health, care coordination resources, and community partners when additional services are needed.
• Identifies barriers such as transportation, insurance coverage, financial concerns, food insecurity, housing instability, or difficulty navigating the healthcare system and connects patients with appropriate resources.
• Reinforces provider-directed care plans and helps patients understand recommended next steps, the importance of follow-up, and available support.
• Maintains clear documentation and communication regarding unresolved patient needs, assigned follow-up responsibilities, and completed interventions.
• Promotes patient engagement, shared decision-making, and self-management by helping patients navigate care in a way that is understandable, accessible, and responsive to their needs.
• Participates in team meetings, daily huddles, and operational improvement activities to strengthen collaboration and clarify follow-up responsibilities.
• Works with clinical and operational leadership to evaluate the effectiveness of triage and care coordination workflows and recommend improvements.

Preventive Care and Population Health

• Supports proactive management of Family Medicine patient populations by identifying patients who are overdue for recommended preventive services, screenings, immunizations, and chronic disease monitoring.
• Reviews assigned patient registries, electronic health record reports, health maintenance records, and other available data to identify care gaps and opportunities for intervention.
• Coordinates targeted patient outreach to improve completion of wellness visits, preventive screenings, immunizations, laboratory monitoring, and other evidence-based services.
• Collaborates with providers and CMAs to incorporate identified patient needs into pre-visit planning and care team workflows.
• Supports chronic disease management through patient education, follow-up, monitoring, reinforcement of care plans, and coordination with the appropriate clinical team members.
• Helps ensure abnormal results, recommended follow-up, and outstanding clinical needs are routed to the appropriate team member and addressed according to established protocols.
• Assists with outreach to patients who have missed appointments, have not completed recommended testing, or require additional support to remain engaged in care.
• Uses available population health tools and reports to prioritize outreach based on clinical need, identified risk, and organizational priorities.
• Supports continuity of care by helping patients transition from episodic care to appropriate ongoing primary care and preventive services.

Quality Improvement and Value-Based Care

• Contributes to Heartland’s value-based care strategies by supporting improvements in preventive care, chronic disease outcomes, patient engagement, care continuity, and applicable quality measures.
• Helps close identified care gaps through patient outreach, coordination of services, tracking of outstanding needs, and timely documentation of completed interventions.
• Participates in pre-visit planning and daily huddles to identify patient care needs, anticipate barriers, coordinate planned services, and support efficient clinic operations.
• Collaborates with providers, nursing staff, quality personnel, and value-based care team members to identify opportunities to improve clinical quality and patient outcomes.
• Supports quality audits, performance improvement initiatives, workflow assessments, and implementation of standardized clinical processes.
• Uses evidence-based protocols and accurate documentation to support quality reporting, clinical decision-making, regulatory compliance, and value-based care performance.
• Assists with monitoring assigned outreach and follow-up activities to identify trends, barriers, and opportunities for improvement.
• Supports patient-centered medical home principles and team-based care by promoting coordinated, proactive, and patient-centered service delivery.
• Maintains awareness of applicable quality measures, organizational performance goals, and value-based care priorities and incorporates these expectations into daily work.
• Helps identify opportunities to improve the effectiveness of patient outreach, reduce missed opportunities for care, and make better use of available clinical resources.
• Participates in evaluating improvement efforts and communicating results, barriers, and recommendations to the appropriate clinical and operational leaders.

Patient Education and Advocacy

• Provides individualized education regarding health conditions, treatment recommendations, preventive services, medications, and self-management strategies.
• Reinforces provider recommendations and helps patients understand the purpose, timing, and importance of recommended care.
• Uses clear, compassionate, culturally responsive communication to promote understanding and engagement.
• Identifies barriers to following treatment recommendations and collaborates with the care team to develop appropriate solutions.
• Advocates for patient needs and connects patients with clinical, pharmacy, behavioral health, social service, and community resources as appropriate.
• Promotes a welcoming, respectful environment consistent with Heartland’s mission and commitment to equitable access to healthcare.

Documentation, Safety, and Professional Practice

• Maintains accurate, timely, and complete documentation in accordance with organizational policies, clinical standards, and applicable regulatory requirements.
• Protects patient confidentiality and complies with HIPAA, infection prevention practices, and other applicable safety and compliance requirements.
• Recognizes, reports, and escalates patient safety concerns, clinical risks, incidents, and near misses through established processes.
• Practices within the RN scope of practice, applicable Kansas laws and regulations, organizational policies, and established clinical protocols.
• Maintains current nursing licensu