RN Care Coordinator-Chronic Disease

UnityPoint-St Luke's Hospital

Full-Time

Days

The Nurse Navigator role provides assistance to patients and families as they navigate through their hospital stay helping them understand their chronic diseases. Specially looks at patient resources, support, assessments, referrals, education, care coordination and general guidance through the continuum of care for this patient population. Navigators promote communication between the patient/patient family and health care providers, eliminate barriers to care, and ensure timely delivery of services.

As a member of the interdisciplinary team, contributes professional nursing knowledge and skills in the provision and management of care to patients and their families. Collaborates with physicians and other health care workers, to assess, plan, implement and evaluate patient care while maintaining a practice environment that reflects the ANA Code for Nurses, Philosophy of Nursing at UnityPoint Health within the structure of the Professional Nurse Practice Model and in collaboration with other care givers.

Clinical Excellence

• Provides education to patients, families, providers, caregivers, multidisciplinary colleagues and the community about the role of the Chronic Disease nurse navigator. Follows up for completion of any identified patient surveys.
• Serves as advocate for patients
• Provides support for patients across the patient experience continuum
• Acts as a liaison between the patient, family, caregivers, and healthcare team
• Practices evidence-based processes including use of clinical guidelines and specialty resources
• Educates and assess patients' understanding of the disease process and treatment options required for informed decisions
• Assists patients with their treatment goals
• Provides comprehensive documentation of patient encounters, education and referrals
• Provides and reinforces education in all phases of care including, but not limited to: treatment, care plan, and symptom management
• Educates and reinforces the issue of adherence to the treatment plan
• Discusses physician visits with patients and families to assess understanding, interpret information as needed, and answer questions
• Contributes to the knowledge base of the healthcare community through involvement in professional organizations, presentations, publications and research
• Rounds with patients and specialty physicians, surgeons, hospitalists, etc.
• Delivers high quality care utilizing the nursing process while demonstrating knowledge and clinical skills of the specialty required on assigned unit in accordance with established policies, procedures and standards of care.
• Utilizes holistic approach (considering biopsychosocial, spiritual, educational, safety, and related criteria) appropriate to the age of the patients and families served in the assigned service area.
• Utilizes critical thinking in making independent judgments and maintains responsibility and accountability for the knowledge of conditions of assigned patients.
• Will complete post discharge follow up phone calls.

Employee Development

• Evaluates and guides team members through coaching and provides immediate feedback and responds to difficult inquiries and problems. Demonstrates the ability to fairly and consistently interpret, apply and follow personnel policies/procedures.
• Coordinates staff education/in-services/specialized skilled training programs including competencies.

Performance Improvement

• Collaborates with Director to develop and implement departmental performance improvement activities and assures ongoing staff participation as directed. Implements action plans, monitors supplies/distribution and chart audits as directed
• Reviews feedback from customers, responds, compiles, and analyzes support data and implements procedural changes as appropriate.

• Bachelor's in nursing
• 2 years hospital nursing experience
• Current license in the state of Iowa or meets criteria established by Iowa Board of Nursing
• Valid driver's license when driving any vehicle for work-related reasons
• Advanced knowledge of field, in-depth knowledge of the "why's".
• Ability to maintain current professional expertise. Exhibits discretion and sound judgment in all aspects of the job.
• Promotes positive interpersonal relations and serves as a role model within the department and with hospital personnel. Writes, reads, comprehends and speaks fluent English.
• Multicultural sensitivity.
• Microsoft Office - basic computer skills.
• Customer/patient focused.
• Critical thinking skills using independent judgment in making decisions.
• Use of usual and customary equipment used to perform essential functions of the position.