Nurse Navigator

Job Description

Job Description

Position Summary

The Nurse Navigator serves as the primary clinical resource and care-coordination professional for residents, promoting physical, psychosocial, spiritual, and overall wellness throughout the resident's journey, including application, move-in, transitions, hospitalization, changes in condition, and periods of crisis. This role conducts comprehensive assessments, coordinates care, removes barriers to services, supports safe transitions across the continuum of care, and collaborates with residents, families, healthcare providers, and interdisciplinary team members to achieve positive outcomes. The Nurse Navigator partners with campus departments, outpatient clinic providers, and community resources to enhance resident health, safety, and well-being; provides education and guidance regarding available services and care options; contributes to quality improvement and risk management initiatives; supports health and wellness programming; tracks and reports resident trends and outcomes; and serves as a key liaison in advancing person-centered care, resident choice, and operational excellence across the community.

Essential Functions

• Serve as the primary health and wellness navigator for Independent Living residents during move-in, hospitalization, rehabilitation, significant health changes, transitions, or crisis situations.
• Complete clinical and functional assessments for prospective Independent Living residents and provide recommendations regarding move-in readiness, support services, and safety needs.
• Conduct ongoing assessments of residents' physical, cognitive, psychosocial, functional, and safety needs and identify risks that may impact independent living.
• Monitor residents experiencing changes in condition and collaborate with interdisciplinary team members to develop appropriate intervention and support plans.
• Coordinate care and services across the continuum, including Independent Living, Assisted Living, Skilled Nursing, Rehabilitation, Home Health, Hospice, hospitals, and community providers.
• Facilitate safe transitions of care following hospitalization, emergency department visits, rehabilitation stays, or other significant health events to reduce risk and improve outcomes.
• Collaborate with physicians, outpatient clinic partners, rehabilitation providers, home health agencies, hospice providers, and other healthcare professionals to support resident health outcomes.
• Identify and remove barriers to healthcare access by connecting residents and families with appropriate services, resources, and support systems.
• Provide resident and family education regarding healthcare options, available services, levels of care, wellness resources, and transition planning.
• Assist residents and families with evaluating care options and making informed decisions regarding supportive services, home care, assisted living, memory care, rehabilitation, or other healthcare resources.
• Serve as a liaison among residents, families, healthcare providers, and campus departments to ensure timely communication and coordinated service delivery.
• Facilitate interdisciplinary resident review meetings and maintain navigation, hospitalization, transition, and high-risk resident tracking processes.
• Document assessments, interventions, referrals, care coordination activities, resident contacts, and follow-up actions in accordance with regulatory and organizational standards.
• Identify residents at risk for falls, self-neglect, cognitive decline, medication-related concerns, social isolation, or unsafe living conditions and coordinate appropriate interventions.
• Support and promote resident health, wellness, and prevention initiatives through education, partnership development, outreach activities, and participation in quality improvement efforts.
• Conduct resident visits in health care settings as appropriate.
• Provide occasional nursing support in the Assisted Living when necessary.
• Perform infection monitoring and response in Independent Living.

Education & Experience

• Current Registered Nurse license required.
• Minimum of 3 years’ experience working with older adults within a Continuing Care Retirement Community, Assisted Living, Nursing Home, or Hospital required.
• Experience in care coordination, discharge planning, case management, navigation, or resident/family support preferred.
• Knowledge of aging services, chronic disease management, functional assessment, risk identification, and community-based health resources.
• Ability to direct resident care and services to the elderly, which meets or exceeds Collington quality and service standards. Ability to work collaboratively with Social Work, outpatient clinicals, physicians, rehabilitation providers, and interdisciplinary teams.
• Requires a valid Driver’s License, as some travel may be required.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job with or without reasonable accommodation. Reasonable accommodation will be determined on a case-by-case basis.

1. Must be able to lift 25 lbs. from the floor to waist.
2. Able to transport a resident in a wheelchair.
3. Able to kneel, bend from waist to floor, stoop, twist torso laterally in all directions and grasp small and large objects.
4. Ability to drive from Collington to partner Skilled Nursing Facilities, as well as Hospitals and Assisted Living facilities within a 40-mile radius.

We also offer the following benefits:
- A comprehensive Medical, Dental, Vision, Life & Disability Plans
- 403 (b) Tax-Deferred Retirement Savings Plan
- Vacation, Sick Leave, Birthday & Holiday Pay
- Employee Assistant Program
- Scholarship opportunities

Salary: Up to $90,000/year based on experience.