Nurse Navigator

Registered Nurse

A professional registered nurse (RN) who offers individualized assistance to patients, families and caregivers to help overcome health care system barriers. Enhances the patient experience and improves the clinical outcome for patients by providing a seamless navigation process throughout the continuum of care. Responsible for collaborating with physicians and members of the interdisciplinary teams to triage, coordinate, and consistently manage patient care by educating the patient and serving as a point of contact for patients and families. Participates in strategic initiatives within the clinical program or service line to include developing, implementing and monitoring navigation activities and sustainability, facilitates shared decision making and patient engagement by forming trusting relationships and addressing patients' communication and health literacy needs, while helping them integrate their values and preferences into treatment decisions. Works for and promotes positive outcomes for patients, providers and the Sutter health care system.

Coordinates patient care through the point(s) of continuum specified by assisting with timely access to care, coordinating/facilitating appointments and services, and accompanying patients to appointments as needed. Facilitates timely coordination of appointments/services. Meets with patient by phone or in person "within designated time" following "designated event" and follows patient per facility-specific guidelines. May include meeting with the patient in both acute and non-acute Sutter Health locations. Coordinates appointments, if applicable, for diagnostic testing, services, and with providers to ensure timely delivery of diagnostic and treatment services. May include accompanying patients to appointments (particularly if there are multiple barriers to care) and/or, providing clarification and literacy-level appropriate education related to the visit. Provides care coordination, symptom management support, guidance, education and advocacy across care settings. Discusses physician visits with patients and families and answers questions. Provides and reinforces education re: treatment, care plan, symptom management, and survivorship concerns. Facilitates shared decision making and patient engagement by forming trusting relationships and addressing patients' communication and health literacy needs, while helping them integrate their values and preferences into treatment decisions. Empowers patients with education and knowledge to help improve patient outcomes and satisfaction. Assesses patients' current and future needs, provides patient access to resources (internal and external), facilitates patient needs assessments, including distress screenings and acuity scales; coordinates/facilitates appropriate referrals. Assesses for and identifies patient/family needs and matches unmet needs to appropriate resources during care continuum, based on clinical guidelines and evidence based practices. Assesses for and works to mitigate barriers to care. Assists patients with access concerns (for screening, diagnosis, and/or treatment, as appropriate) and assists with paperwork as needed. Makes referrals for services based on patient/family needsi.e., education, finances, psychosocial, survivorship, transportation, child care, lodging. Facilitates access to physicians and services. Facilitates appropriate medical record availability at scheduled appointments as needed. Facilitates language translation or interpretation services. Facilitates financial assessment and referrals along with assisting with completing forms as needed. Facilitates linkages to follow-up services. As appropriate, facilitates screening for and access to clinical trials, molecular testing and/or genetic counseling. Builds partnerships with local agencies and groups (e.g., referrals to other services and/or support groups). Facilitates distress and acuity screening and makes appropriate referrals. Establishes and maintains close collaboration with providers and care team to communicate effectively ensuring seamless patient care and care coordination. Communicates and collaborates with involved physicians and staff members to facilitate individualized patient care plans and communication between care disciplines. Maintains communication with patients, families, and health care providers to monitor patient satisfaction with the care experience. Ensures that navigator functions and activities remain within scope of defined role. Provides triage and support services (e.g., symptom management, emotional support, education, resource referral) for patients//families in collaboration with attending physicians and the care team. Tracks navigation program metrics and quality indicators, documents patient interactions and progression, and communicates navigation activities to physicians and the care team. Assists with tracking, documentation, and outcome reporting for navigation services. Assists with ongoing navigation program assessment and identification of process improvement opportunities. Assists with and/or attends meetings for Sutter Health accreditation endeavors. Assists with annual accreditation requirements related to navigation and as directed by administration. Actively participates in multidisciplinary conference, assisting with preparing conference materials and providing patient follow-up as needed. Actively participating in multidisciplinary care patient presentation and care planning. Assists with coordination of multidisciplinary conference(s) as needed. Assists with patient follow-up as needed. Assists with and/or attends conferences. Participates in community health promotion and awareness programs. Conducts health promotion and awareness programs in community as appropriate. Attends community health fairs and screenings; provides community education presentations as appropriate. Facilitates/attends support groups as appropriate. Conducts and/or assists with a Community Needs Assessment at least once every three years to meet the American College of Surgeons Commission on accreditation requirement(s). Teaches health topics, including risk reduction, to those interested within the community. Facilitates and/or attends support groups. Communication (Oral and Written) Consistently communicates with patients, physicians and other Sutter Health staff in a courteous, professional manner that reflects the desired service outcomes of the department. Prepare patient information materials as requested. Maintains confidentiality of patient information at all times. Quality Participate in ongoing quality assessment/improvement, ensuring that there is a continuous process of measuring and enhancing quality. Consistently demonstrates Customer Service principles in daily practice. Must be detail-oriented and possess strong organizational skills. Must possess excellent follow-up and follow through skills. Participate in ongoing education opportunities and training Productivity/Efficiency Ability to prioritize goals and work accurately and efficiently. Sutter Health Citizenship Adheres to all policies and procedures (i.e. Administrative and Human Resources), practices safe work habits, and engages in good business standards and practices. Service Standards Consistently exhibits behaviors set forth in the attached Sutter Health Codes of Conduct.