GI Nurse Navigator: Care Coordinator & Patient Advocate

Job Summary Kaiser Permanente nurses are guided by an integrated nursing model that places patients and families in the center. The Registered Nurse (RN) Navigator practices professional nursing as defined by the Georgia Registered Professional Nurse Practice Act and by organizational policies, procedures, and guidelines. Using the nursing process, an RN Navigator provides education and resources to facilitate informed decision making and timely access to quality health and psychosocial care throughout all phases of the care continuum. Serves as an additional point of contact for patients, families, caregivers, and referring physicians to assist with accessing clinical and supportive care services offered within and outside of Kaiser Permanente Georgia. Develop and maintain high quality evidence-based care processes through patient education and training to achieve optimal patient outcomes. Maintains a strong component of patient/family advocacy with day-to-day review and coordination of multidisciplinary services. Provide outreach to connect patients to educational information, resource partners, or support groups. Assists patients and families in understanding their diagnosis, treatment options, and the resources available to them within Kaiser Permanente. Responsibilities include but are not limited to assessment, symptom management, analysis of data, planning, case management, and implementation of interventions and evaluation of the outcomes for patients with past, current, or suspected chronic diagnosis. Develop and facilitate a plan of care in consultation with treating physicians, patient, their support network, and family members, to assist the patient in understanding/navigating their individualized plan. Serves as an essential link between patients, healthcare providers, family, and support team, and any other individuals involved in the coordination of care. Facilitate changes in the plan of care and brokering necessary services to facilitate a patient-centered care environment. Service settings may include, but are not limited to the hospital, outpatient, home, or other supportive environments. Performs care assessments and triage of new and ongoing patients (including patients on a clinical research study) by phone, in the clinic, or in coordination with other healthcare team members by other communication methods. Facilitates appointments for consults, procedures, and support services within the established service lines. Facilitates the availability of pathology reports, radiographic studies and additional pathology testing needed for the member prior to or after their consult appointment within the specialty department. Standardizes patient education materials by developing and maintaining a resource library specific to the specialty patient population to be utilized by both the patients and the healthcare team. Delivers patient and family education prior to initiation of treatment plan and remains available throughout the treatment process for questions or concerns from patient/family or caregiver. Follows the patient throughout the entire continuum of care while an active Kaiser Permanente KPGA patient and continue to collaborate with external healthcare members regarding inpatient treatment and discharge planning. Monitor patient compliance with patient treatment plan. Assist patients with referrals to outside resources and care coordination as needed. Responsible for outreach to maintain a positive working relationship as appropriate with key customers (physicians, office staff, diagnostics, radiology staff, inpatient nurses, lab staff, primary care, palliative care, and all other specialty services needed). Assists the patient with symptom management side effects of treatments keeping the physician updated with their side effects, interventions, medication needs and any dose limiting toxicities that are identified promptly. Develop a database of community resources for patients (ex. American Cancer Society, local support groups etc.). Central point of contact for all navigated patients involved in data collection or research projects. Central point of contact with the clinical research coordinator. Identify potential patients for Clinical Trials protocols and coordinates with the research coordinator to consent the patient. Work with quality staff, research team members, and other healthcare team partners to collect data, monitor trends, track outcomes, support and/or participate in research projects, and facilitate strategic planning processes related to patient care. Foster relationships with Kaiser Enterprise for visiting members that may be requiring treatment while in the Georgia region. Responsible for ongoing development and implementation of the Nurse Navigator role at Kaiser Permanente and within the community. Carry out various direct patient care activities within scope of practice and accurately document the patient care in the patient medical record according to KP and department policy. Serves as a preceptor, resource, and mentor for new members of the healthcare team and nursing students. Develop a departmental outreach resource database to connect patients and individuals to services and community resources approved by the Chief of relevant specialty department. Ensure that the database is easily accessible by the healthcare team and updated on a regular basis. Maintain knowledge about disease specialty, treatments, delivery of Navigator services. Participate in all relevant trainings and networking calls/opportunities. Analyzes new knowledge gained from conferences, workshops, professional literature, or hands on training and assimilates this knowledge into clinical practice. Specialty specific job responsibilities including but are not limited to medication teaching, device programming and maintenance, maintaining relevant databases, patient education, self-injection teaching, and policy review. Identifies clinical quality indicators for relevant patient population and conducts systematic reviews when required. Implements methods and processes to sustain change in nursing practice, programs of care, and clinical innovation. Facilitates evaluation of records by physicians, peers, and quality standards, according to protocols and receives and implements constructive directives. Participates in specialty department meetings as needed. Performs any other job-related duties as assigned. Job Summary Kaiser Permanente nurses are guided by an integrated nursing model that places patients and families in the center. The Registered Nurse (RN) Navigator practices professional nursing as defined by the Georgia Registered Professional Nurse Practice Act and by organizational policies, procedures, and guidelines. Using the nursing process, an RN Navigator provides education and resources to facilitate informed decision making and timely access to quality health and psychosocial care throughout all phases of the care continuum. Serves as an additional point of contact for patients, families, caregivers, and referring physicians to assist with accessing clinical and supportive care services offered within and outside of Kaiser Permanente Georgia. Develop and maintain high quality evidence-based care processes through patient education and training to achieve optimal patient outcomes. Maintains a strong component of patient/family advocacy with day-to-day review and coordination of multidisciplinary services. Provide outreach to connect patients to educational information, resource partners, or support groups. Essential Responsibilities Assists patients and families in understanding their diagnosis, treatment options, and the resources available to them within Kaiser Permanente. Responsibilities include but are not limited to assessment, symptom management, analysis of data, planning, case management, and implementation of interventions and evaluation of the outcomes for patients with past, current, or suspected chronic diagnosis. Develop and facilitate a plan of care in consultation with treating physicians, patient, their support network, and family members, to assist the patient in understanding/navigating their individualized plan. Serves as an essential link between patients, healthcare providers, family, and support team, and any other individuals involved in the coordination of care. Facilitate changes in the plan of care and brokering necessary services to facilitate a patient-centered care environment. Service settings may include, but are not limited to the hospital, outpatient, home, or other supportive environments. Performs care assessments and triage of new and ongoing patients (including patients on a clinical research study) by phone, in the clinic, or in coordination with other healthcare team members by other communication methods. Facilitates appointments for consults, procedures, and support services within the established service lines. Facilitates the availability of pathology reports, radiographic studies and additional pathology testing needed for the member prior to or after their consult appointment within the specialty department. Standardizes patient education materials by developing and maintaining a resource library specific to the specialty patient population to be utilized by both the patients and the healthcare team. Delivers patient and family education prior to initiation of treatment plan and remains available throughout the treatment process for questions or concerns from patient/family or caregiver. Follows the patient throughout the entire continuum of care while an active Kaiser Permanente KPGA patient and continue to collaborate with external healthcare members regarding inpatient treatment and discharge planning. Monitor patient compliance with patient treatment plan. Assist patients with referrals to outside resources and care coordination as needed. Responsible for outreach to maintain a positive working relationship as appropriate with key customers (physicians, office staff, diagnostics, radiology staff, inpatient nurses, lab staff, primary care, palliative care, and all other specialty services needed). Assists the patient with symptom management side effects of treatments keeping the physician updated with their side effects, interventions, medication needs and any dose limiting toxicities that are identified promptly. Develop a database of community resources for patients (ex. American Cancer Society, local support groups etc.). Central point of contact for all navigated patients involved in data collection or research projects. Central point of contact with the clinical research coordinator. Identify potential patients for Clinical Trials protocols and coordinates with the research coordinator to consent the patient. Work with quality staff, research team members, and other healthcare team partners to collect data, monitor trends, track outcomes, support and/or participate in research projects, and facilitate strategic planning processes related to patient care. Foster relationships with Kaiser Enterprise for visiting members that may be requiring treatment while in the Georgia region. Responsible for ongoing development and implementation of the Nurse Navigator role at Kaiser Permanente and within the community. Carry out various direct patient care activities within scope of practice and accurately document the patient care in the patient medical record according to KP and department policy. Serves as a preceptor, resource, and mentor for new members of the healthcare team and nursing students. Develop a departmental outreach resource database to connect patients and individuals to services and community resources approved by the Chief of relevant specialty department. Ensure that the database is easily accessible by the healthcare team and updated on a regular basis. Maintain knowledge about disease specialty, treatments, delivery of Navigator services. Participate in all relevant trainings and networking calls/opportunities. Analyzes new knowledge gained from conferences, workshops, professional literature, or hands on training and assimilates this knowledge into clinical practice. Specialty specific job responsibilities including but are not limited to medication teaching, device programming and maintenance, maintaining relevant databases, patient education, self-injection teaching, and policy review. Identifies clinical quality indicators for relevant patient population and conducts systematic reviews when required. Implements methods and processes to sustain change in nursing practice, programs of care, and clinical innovation. Facilitates evaluation of records by physicians, peers, and quality standards, according to protocols and receives and implements constructive directives. Participates in specialty department meetings as needed. Performs any other job-related duties as assigned. Experience Basic Qualifications: Minimum three (3) years of current RN clinical experience in area of specialty. Education Associates degree in nursing. High School Diploma or General Education Development (GED) required. License, Certification, Registration Registered Professional Nurse License (Georgia) required at hire Basic Life Support required at hire Additional Requirements N/A Preferred Qualifications Experience as a Clinical Nurse Coordinator, Clinical Navigator, or Case Manager preferred. Bachelors (BSN) degree. #J-18808-Ljbffr Kaiser Permanente