Clinical Care Navigator - Full Time

General Summary:

This Registered Nurse is responsible for providing professional nursing care in the outpatient oncology setting, following established standards and practices. Assists physicians and staff in coordinating patient care. Functions as primary liaison between patients, staff and physicians. Provides comprehensive patient care of the Oncology patient, triage of clinical phone calls. Exhibits four core values of respect, integrity, innovation and compassion.

The Clinical Care Navigator (CCN) works with the patient and their family, Oncologist and other members of the health care team to coordinate care resources and services to improve the quality and effectiveness and decrease the cost of patient care. The CCN utilizes communication skills to promote patient engagement, self-management, and shared decision-making.

Supports the Patient-Centered Medical Home (PCMH) by working with patients, families, providers and other staff to promote timely access to needed care, provide daily continuity of care coordination, and coach patients, families and care givers to understand the patient care plan and self-care management responsibilities.

Principal Duties & Responsibilities:

Standard 1 – Provides clinical support to patients

• Responsible for addressing all clinical calls and clinical issues, for assigned providers and others as needed
• Educates patients and families about diagnostic procedures, medications, nutrition and maintenance of health throughout treatment course
• Works closely with providers to follow treatment plan for patient
• Works with Care navigator to obtain referrals to meet patient needs re: Social Determinants of Health
• Maintains/reviews patient records, charts and other pertinent information
• Calls in patient prescriptions and refills per provider order
• Reviews lab and x-ray results and takes appropriate action on results
• Works on inbox tasks, Triage RN, assigned providers, and others as appropriate
• Completes New Patient Education sessions as needed
• Assists Clinical Research Coordinators in identification and work-up of potential protocol patients.
• Follows all research protocols as directed
• Completes and submits indigent drug forms for appropriate patients.
• Responds to/refers incoming patient treatment-related phone calls. Instructs patient and family regarding medications and treatment
• Maintains patient confidentiality
• Completes referral to community resources as required by patients
• Seeks appropriate tasks when primary tasks are completed and assists co-workers as needed
• Will have the flexibility to work in any of our offices as directed by team physicians
• Assists patient and family in processing of insurance and disability claims as needed

Example of CCN-Related Essential Duties:

1. Serves as a key point of contact between the patient, primary care physician and the extended care team through coordination of patient activities and the appropriate utilization of services.

2. Contact patients, families, and caregivers post hospital stays &/or ED visits to discuss discharge planning and educational needs: participate in Interdisciplinary Team (IDT) meetings as needed.

3. Collaborate and make recommendations to hospital discharge planner on transition services, and addressing Social Determinants.

4. Serve as a supplemental resource for the Oncologist and PCP/Hospitalist involved in discharge planning.

5. Communicate with Oncologist and care team on transition planning, barriers, and recommendations for a successful discharge.

6. Coordinate with the TOC (Transition of Care) team to complete medication review/reconciliation, ensure post-discharge services are in place including follow up appointment with the PCP.

7. Complete TOC documentation in the EHR and make referrals to Social Worker, Palliative Care and Hospice as indicated.

8. Ensures patient, family and caregiver understanding of the plan including; condition management, medications, tests, referrals, and services.

9. Performs other related duties as assigned.

Standard 2 – Professional Growth and Development

• Attends nursing meetings to expand knowledge of oncology nursing
• Maintains certifications required for the position
• May serve as the super-user for the computer system

Standard 3 – Behavior

Communication

• Exhibits excellent written and verbal skills.
• Utilizes assertive communication skills in addressing concerns or problems.
• Participates as a member of organization/institutional committees as requested.

Initiative

• Able to conceive innovative strategies and ideas for the center, exhibiting “out of the box” thinking.
• Performs job duties effectively with minimal direction.
• Initiates new ideas and projects that enhance patient care or other aspects of services and care.

Team Orientation

• Service as a team member among co-workers and peers.
• Participates in TCCC activities that enhance patient care and work surroundings.

Patient Privacy

• Participates in assuring that all personally identifiable healthcare information of the patient will be maintained confidential.
• Assures that any oral or written disclosure of personally identifiable healthcare information should be minimum necessary to serve the purpose of performing quality care to the patient.
• Understands any disclosure outside payment, treatment, or healthcare operations requires written patient authorization in each instance.

Respect

• Understands and demonstrates sensitivity to the cultural diversity of patients, staff, and visitors.

Knowledge, Skills & Abilities Required:

Required:

Licensure as a Registered Nurse, BSN preferred. 1-2 years nursing experience preferred. Ohio and Michigan RN license required. ONS Chemotherapy and Biotherapy certification within 6 months of hire and bi-annual renewal required. Oncology Certified Nurse (OCN) required within one year of eligibility. Excellent communication and interpersonal skills required. Consistently arrives at work, in professional attire, on time and completes all tasks within established time frame. Demonstrates adaptability to expanded roles. Current CPR certification required.

• Ability to excel in an environment of constant change, problems and unexpected interruptions, where extreme pressure to deliver results is expected.
• Skills in establishing and maintaining effective working relationships with physicians and non-physician support staff.
• Knowledge of computer systems and applications.
• Working knowledge of Clinical IT applications.

Preferred:

• Knowledge of professional nursing theory, regulations and practices to give and evaluate patient care
• Knowledge of common safety hazards and precautions to establish/maintain a safe working environment.
• Knowledge of chemotherapy and biotherapy to give and evaluate response to therapy and to ensure a safe working environment.
• Thorough knowledge base regarding chemotherapy drugs, side effects, and treatment regimens.
• Skill in applying and modifying the principles, methods and techniques of professional nursing to provide ongoing patient care.
• Skill in identifying problems and recommending solutions.
• Skill in preparing/maintaining records, writing reports and responding to correspondence.
• Skills in IV access including central venous access devices may be helpful
• Ability to maintain quality control standards
• Ability to react calmly and effectively in emergency situations
• Ability to communicate clearly and effectively verbally and in writing.