Population Health Nurse Navigator Full Time (80 hours per pay period)

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Location

Kalamazoo-301 John St. - Business Office Building

Title

Population Health Nurse Navigator Full Time (80 hours per pay period)

The Nurse Navigator will guide patients through the health care system, establishing contact with newly diagnosed (cardiovascular/stroke/ortho/oncology) patients within the care setting as early as possible in the episode. This position will work closely with primary care physicians, surgeons, specialists, ancillary services, and other health care facilities. He/she acts as a liaison between the patient and all of the services required within the system and in the community. The navigator offers patients and their families' psychosocial support, access to resources, and educates on disease specifics and treatment options. In addition, the position works with designated physicians and teams to develop and maintain clinical pathways and measure outcomes. The Nurse Navigator behaves in a professional manner, and consistently demonstrates and promotes the values of respect, honesty, care, and dignity for the patient and all members of the health care team. Within applicable service lines, this position coordinates care for patients in the Bundled Payment (BP) program. The Nurse Navigator will be responsible for ongoing evaluation, quality improvement and outcomes of the BP program patients within their service line scope. Employees providing direct patient care must demonstrate competencies specific to the population served.

Bachelor's degree in nursing and 5 years of professional nursing in specific service line or related area required. Master's degree preferred.

Licensed Registered Nurse in good standing with the State of Michigan; BLS certification required within 6 months of hire.

Must provide evidence of successful completion (or an approved audit) of a CPR training course within the past 2 years or successfully complete a CPR training course (or audit with approval) within 6 months of hire. 

Oncology Nursing Certification required within 3 years of hire (Cancer Care Center only)

BBC Cancer Center Only: Preferred Eligible Candidate:  BSN Required. Alternative Eligible Candidate: ASN with 7 years of experience in Oncology with agreement that BSN must be obtained within 3 years. 

Breast Nurse Navigator

The Breast Nurse Navigator will guide patients through the health care system, establishing contact with newly diagnosed Breast/Oncology patients and will work closely with Radiologists along with all other primary care physicians, surgeons specialists, ancillary services and other health care facilities. Within applicable service lines, this position coordinates care for patients according to the care plan program. The Breast Nurse Navigator is responsible for participation in the assessment, planning, implementation and evaluation of health services provided by Bronson.  Breast Nurse Navigator is an integral part of coordination and support for the patient as he/she moves through the continuum of care from the onset of diagnosis through treatment phases into Survivorship. 

Population Health Nurse Navigator 

The Population Health Nurse Navigator serves as a clinical and coordination resource supporting the Care at Home Advanced Practice Providers (APPs) as they deliver longitudinal, in-home primary and palliative care to high-risk patients. The role conducts proactive, analytics-driven outreach to identify and engage high-risk, high-utilization patients appropriate for home-based services, and performs telephonic triage to assess patient needs and determine whether an APP home visit or an alternative disposition is warranted. The Navigator manages and adjusts the APPs' schedules, serves as the single point of contact for incoming referrals and patient communication, and completes follow-up calls that support hospital and skilled nursing facility (SNF) transitions to prevent avoidable readmissions. Working on behalf of the APPs, this position helps high-risk patients navigate the post-acute process and community resources, and coordinates with the palliative care team and SNF/post-acute care managers to ensure an appropriate plan of care is in place. Clinical expertise in care management, transitions of care, and telephonic assessment is required, along with strong critical-thinking and care-coordination skills. This position supports value-based care and ACO population health goals by improving access to primary care for high-risk patients and reducing unnecessary hospital utilization

Heart Failure Nurse Navigator

The HF NN serves as a clinical guide and advocate for patients admitted to BMH with Congestive Heart Failure. The role of the HF NN is to improve outcomes for patients with heart failure by providing education related to medication adherence, fluid management, and early signs of worsening symptoms. The NN will reinforce discharge instructions and support transition to home or post-acute settings. The HF NN will also coordinate any post discharge needs with outpatient heart failure programs, cardiology and primary care to prevent readmissions. Clinical expertise in heart failure and chronic disease management is required. This position will require weekend and holiday coverage on a rotating basis.

Advanced Illness Nurse Navigator

This role blends clinical expertise, care coordination, and compassionate communication to support patients with serious or life-limiting illnesses.

The Advanced Illness Nurse Navigator serves as a clinical guide and advocate for patients and families facing serious, chronic, or life-limiting illnesses at BMH. This role facilitates timely access to palliative and supportive care services, ensure alignment of care with patient goals and values, and supports high-quality coordinated care across settings. The Nurse Navigator collaborates with interdisciplinary teams to reduce symptom burden, prevent unnecessary hospitalizations, and improve quality of life.

In the office-based role- Leads and/or participates in the identification of high-risk patients prior to elective surgery and facilitates the optimization of their health status prior to their scheduled procedure including referrals for co-morbid conditions, weight management and/or smoking cessation. 

In the hospital-based role- Participates in multidisciplinary rounds and/or conferences and acts as a resource for clinicians and case managers to assure that patient care plan is followed for the assigned programmatic clinics.  Involvement in Value Based Programs:  Engages all participating patients and families and makes them aware of plan of care for the episode, information resources, support programs and services.  *Acts as a representative of the program within the entire community, participating in public speaking and other related activities, especially within the organization.  *Maintains any required database for the patients and or program by inputting required patient data, as well as, tracking patient volumes, clinical outcomes and patient satisfaction.  *Establishes action plans that support Bronson's key initiatives for the BP program. Travel is required for this position (as we serve Kalamazoo and Calhoun County with Nurse Navigator services)

ESSENTIAL DUTIES & RESPONSIBILITIES (Breast) Nurse Navigator

Keeps in contact with patients as they are receiving their care.  Rounds daily on all assigned patients.

Participates in multidisciplinary rounds and/or conferences.

Engages all Medicare bundled payment patients and families and makes them aware of plan of care for the episode, information resources, support programs and services.

Acts as a representative of the BP program within the entire community, participating in public speaking and other related activities, especially within the organization.

Proactively develops the Nurse Navigator role with the goals of improving the experience for referred patients and the referring physicians.

Ensures that the appropriate tests, diagnostics, and procedures are ordered for patients.

Assists with implantation of dynamic patient-centered record.

Becomes familiar with various insurance and referral policies.

Acts as a resource for clinicians and case managers to assure that patient care plan is followed for the assigned programmatic clinics.

Is cognizant of the rising cost of healthcare and how that impact consumers (patients).

Develops and ensures developed budgets effectively utilize resources (both human and financial).

Monitors budget adherence and identifies trends or issues that may jeopardize achievement of same.

Puts appropriate action plans in place to ensure achievement of budget goals.

Shift

First Shift

Time Type

Full time

Scheduled Weekly Hours

40

Cost Center

9177 Bronson Network LLC (BHG)

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