The Nurse Navigator is responsible for providing nursing care coordination, transitional care, disease management, patient education, and advocacy for patients with complex healthcare needs. This position supports patients throughout hospitalization and discharge, with a primary focus on ensuring continuity of care between hospitals, the Muckleshoot Health and Wellness Center (MHWC), specialty providers, and other healthcare and community services. The Nurse Navigator works collaboratively with patients, families, MHWC providers, the Social Worker, hospital care teams, and outside healthcare organizations to identify barriers to care, coordinate services, and promote successful transitions following hospitalization.

*This role is onsite, Monday-Friday. 

This list is intended only to illustrate the various types of work that may be performed.  The omission of specific statements does not exclude them from the position if the work is similar, related or logical assignment to the position.

1. Coordinates care for MHWC patients who are hospitalized, transitioning from inpatient care, or have complex medical and disease-management needs while the patient is in the hospital. This position will require visits to hospitalized patients.
2. Communicates hospitalizations, significant changes in patient status, co-ordinates care with clinic providers and anticipated discharge needs to the patient's MHWC primary care provider and appropriate members of the care team.
3. Facilitates communication and exchange of relevant clinical information between hospitals, MHWC providers, specialists, pharmacies, and other healthcare organizations to promote continuity of care.
4. Reviews hospital discharge plans along with the social worker and proactively identifies medical, medication, equipment, transportation, social, behavioral, or other barriers that may affect a safe and successful transition to the home.
5. Conducts timely post-discharge follow-up with patients through telephone, in-person visits, or other appropriate methods to assess recovery, identify concerns, and ensure follow-up needs are addressed.
6. Performs medication reconciliation and reviews discharge instructions, treatment plans, referrals, laboratory testing, imaging, and other recommended follow-up care with patients and the healthcare team.
7. Monitors clinical alerts, changes in patient condition, and other identified health concerns and communicates or escalates concerns to the appropriate provider in accordance with established clinical protocols and scope of practice.
8. Coordinates primary care, specialty care, and other healthcare appointments; assists with appointment reminders and patient preparation; and helps arrange transportation or other resources when barriers to care are identified.
9. Provides individualized patient and family education regarding diagnoses, medications, treatment plans, warning signs, follow-up recommendations, and chronic disease management.
10. Works collaboratively with the Social Worker to identify and address psychosocial concerns and social determinants of health that may affect the patient's ability to access care, follow treatment recommendations, or successfully manage their health.
11. Screens for patient distress and psychosocial needs and facilitate appropriate referrals for behavioral health, social services, community resources, transportation, and other services.
12. Serves as a patient advocate and liaison between patients, families, MHWC, hospitals, specialists, and outside healthcare organizations to promote coordinated, patient-centered care.
13. Provides culturally responsive nursing care that respects Tribal values, traditions, family involvement, patient preferences, and the needs of the community.
14. Maintains accurate and timely documentation of nursing assessments, patient communication, care coordination activities, education, interventions, referrals, follow-up, and outcomes in the electronic health record.
15. Participates in Nursing activities in clinic with chronic disease management programs and cross covers other nurses in clinic when needed.
16. Adheres to applicable laws, regulations, clinical standards, organizational policies, and procedures.
17. Maintains the privacy and confidentiality of all protected health information in accordance with organizational policies and procedures and applicable state and federal regulations.
18. Because of the Tribe's commitment to community service and the well-being of its members, each employee may be expected to perform a wide range of office and field duties from time to time. Such duties may or may not be related to their regular responsibilities.

Required:

• Graduation from an accredited Registered Nursing program.
• Two (2) years of hospital clinical experience.

Skills:

• Phlebotomy. Physical assessment. Communication (oral and written). Problem solving. Interviewing patients. Time management. Crisis intervention. Initiating appropriate emergency response. Maintaining and establishing working relationships and working with diverse populations and cultures. Handling several tasks simultaneously. Reading and following written medical orders.

Ability:

• Ability to communicate effectively, both verbally and in writing, with patients, families, healthcare professionals, and outside organizations.
• Ability to establish and maintain trusting, professional, and culturally respectful relationships with patients and families.
• Ability to work independently, organize and prioritize multiple patient needs, manage time effectively, and adapt to changing clinical situations.
• Ability to work collaboratively as a member of the healthcare team.
• Ability to use electronic health record systems and other technology required for care coordination and communication.

Knowledge:

• Knowledge of professional nursing principles, practices, and standards.
• Knowledge of transitional care, hospital discharge processes, chronic disease management, and care coordination.
• Knowledge of medication reconciliation and post-discharge nursing assessment and follow-up.
• Medical terminology, anatomy, physiology and pathophysiology. Equipment, supplies and materials needed for medical treatment. Basic laboratory procedures including preparation and screening. Health care system structure and function. Infectious disease management, control and safety standards. Effective supervision. Medical record documentation. Basic pharmacology. Human systems (wellness, illness, growth and development, nutrition, behavioral, psycho-social and family systems).

The working conditions described here are representative of those that must be met by an employee to successfully perform the essential duties of this class. Work is performed mostly in a clinic setting. While performing the duties of this job, the employee is continuously required to talk, see and hear. The employee is occasionally required to sit, walk, bend, balance, crouch, kneel, reach and twist; and frequently use both hands to handle, or feel objects including medical instruments, and reach with hands and arms. The employee must occasionally lift, move, push/pull and/or carry up to 40 pounds. Specific vision abilities required by this job include close and far acuity and the ability to adjust focus. Hand-eye coordination is necessary to operate computers and various pieces of office equipment.  The noise level in the work environment is usually moderately quiet.