Specialty Nurse Navigator - Lung Program - Bethesda North

Job Overview

This position provides comprehensive care coordination supporting a holistic and
longitudinal approach across the continuum related to specific episodes of
care. This position assists with informed decision making, collaborating with a
multidisciplinary team to allow for timely screening, intervention, and
increased supportive care throughout the patient experience. This position
provides individual assistance to patients, families, and caregivers to help
identify and overcome barriers which may hinder quality, medical, and
psychosocial patient care. 

Job Requirements

Associate's Degree in Nursing 
Equivalent experience accepted in lieu of degree
RN, Registered Nurse
Progressive nursing experience in hospital, ambulatory or home health 
Strong customer service and communication skills 
Ability to work with Physicians and others and collect data, generate reports,
and provide analysis via computers and EMR
2-3 years experience Clinical Nursing Experience in the specialty area for which
Navigator position is being hired (i. e.: orthopedics, cardiac, oncology, etc.) 
2-3 years experience Clinical Nursing Experience in home care preferred

Job Responsibilities

Assess the patient's plan of care and develops, implements, monitors, and
documents utilization of resources and progress of the patient through their
care, facilitating options and services to meet the patient's healthcare needs.
Evaluates the medical necessity and appropriateness of care, optimizing patient
outcomes. Serves as a liaison for referring physicians and connections to
community resources. 
Assesses clients’/caregiver(s)’ activation, literacy level and self-management
capabilities. Evaluate patient functional abilities and limitations. Determine
if intervention is needed. Assist the patient/family through diagnostic
services, treatment and care and monitor clinical progress for defined episodes
including transition to post-acute environment. Communicates delays in care,
functional status and changes in clinical status to specialist and primary care
provider (PCP) and coordinates required follow-up and monitoring. 
Educates client and family/caregiver(s) on diagnosis, course of care,
medication, medication reconciliation and nutrition and moves client toward
self-management. Collaborates with the patient and family when setting goals;
initiate transition planning and recommends additions to or modification of
referring orders. Establish treatment goals that are functional, measurable and
patient related. Establish and implement a patient centric plan of care that is
aligned with clinical protocols in acute, ambulatory and post-acute environment
to achieve treatment goals.
Reviews and analyzes model of care clinical pathway process improvement
activities for appropriate populations of patients to achieve the optimal
clinical, financial, operational, and satisfaction outcomes. Participates in
ongoing staff development Establish and promote a collaborative relationship
with 
Provide support for data collection and reporting, as needed, for value based
contracts.

Other Job-Related Information

Working Conditions

Climbing - Occasionally
Concentrating - Frequently
Continuous Learning - Frequently
Hearing: Conversation - Consistently
Hearing: Other Sounds - Consistently
Interpersonal Communication - Consistently
Kneeling - Rarely
Lifting <10 Lbs - Occasionally
Lifting 50+ Lbs - Rarely
Lifting 11-50 Lbs - Rarely
Pulling - Occasionally
Pushing - Occasionally
Reaching - Occasionally
Reading - Frequently
Sitting - Frequently
Standing - Occasionally
Stooping - Rarely
Talking - Consistently
Thinking/Reasoning - Frequently
Use of Hands - Frequently
Color Vision - Frequently
Visual Acuity: Far - Occasionally
Visual Acuity: Near - Consistently
Walking - Occasionally

TriHealth SERVE Standards and ALWAYS Behaviors
At TriHealth, we believe there is no responsibility more important than to SERVE
our patients, our communities, and our fellow team members. To achieve our
vision and mission, ALL TriHealth team members are expected to demonstrate and

live the following

Serve: ALWAYS…

• Welcome everyone by making eye contact, greeting with a smile, and saying

• Acknowledge when patients/guests are lost and escort them to their destination

• Refrain from using cell phones for personal reasons in public spaces or

• Recognize and take personal responsibility to address and recover from service

• Offer patients and guests priority when waiting (lines, elevators)

• Work on improving quality, safety, and service

• Respect cultural and spiritual differences and honor individual preferences.

• Respect everyone’s opinion and contribution, regardless of title/role.

• Speak positively about my team members and other departments in front of

• Value the time of others by striving to be on time, prepared and actively

• Pick up trash, ensuring the physical environment is clean and safe.

• Be a good steward of our resources, using supplies and equipment efficiently

• Acknowledge wins and frequently thank team members and others for

• Show courtesy and compassion with customers, team members and the community