Title: NURSE NAVIGATOR – Heart Failure
Scheduled Hours:
Job Summary:
Navigates patient and family members through the diagnosis, treatment, and follow-up of the patient throughout the continuum of care ensuring smooth transitions between care settings. Collaborates with a multi-disciplinary team to support patients and families in addressing the following dimensions of care: education, psychosocial needs, advocacy, and continuity of care.
Provides continuity of care by ensuring smooth transitions between care settings. Develops a relationship with patient and their multidisciplinary team to facilitate and/or navigate through subsequent treatment and follow-up to reflect continuity of care.
Completes a nursing assessment to identify the patient's individualized needs and collaborates with multidisciplinary team and other departments to develop an interdisciplinary plan of care.
Supports the patient and family by providing education, addressing psychosocial needs, advocating, providing continuity of care and identifying barriers to care. Navigates patients and family members throughout the diagnosis, treatment and follow-up of the patient throughout the continuum of care.
Provides expert clinical advice to the multidisciplinary team in designing collaborative teaching plans/programs and in planning/providing patient/family education and discharge planning including wellness and health maintenance within designated specialty.
Coordinates timely, seamless, evidenced based care across the care continuum resulting in best patient outcomes. Evaluates, selects or designs patient education materials on specific disease site programs. Provides education and outreach programs to patients, Aurora staff and to members of the community.
Assist leadership in developing program vision, goals and objectives. Assists in the development, implementation and maintenance of quality programs that include best practice patient care outcomes including quality of life, and enhanced patient loyalty.
Position Requirements: