The Community Based Nurse Navigator (CBNN) is accountable for the high-risk patient population of Tandigm PCPs. As such, s/he takes responsibility for ensuring the continuity and coordination of patient care delivery by assessing patient needs; developing (in collaboration with the patient, patient family, and PCP) a Plan of Care (POC) that addresses those needs; identifying and leveraging appropriate resources (within the parameters of established networks, programs, and policies) to implement the POC; and regularly evaluating patient progress against the POC. The CBNN performs clinical assessments and provides nursing care within the scope of practice and licensure. The CBNN works with primary care physicians, nurse practitioners, and specialists to facilitate immediate treatment and coordinate care to ensure quality patient care. Finally, the CBNN communicates patient care updates and other relevant information to all stakeholders (Care Team Manager, PCP and office staff, Medical Director, ancillary providers) in a timely and reliable manner.
The CBNN uses advanced nursing knowledge, evidence-based best practice, critical thinking skills, and excellent oral and written communication skills to ensure appropriate utilization of resources and patient quality outcomes. To all of this, the CBNN candidate brings a passion for the work, a belief in the role, and a commitment to the patients and physicians served.
The CBNN carries out the majority of these responsibilities in the field, meeting patients and providers in PCP offices and other community based settings, augmenting patient encounters telephonically as needed and appropriate. The schedule for this full-time exempt position is Monday through Friday, generally 8 AM-4:30 PM, though some evening and/or Saturday hours may be required to accommodate patient and/or PCP schedules. In-person attendance at corporate headquarters for regularly scheduled clinical rounds, department staff meetings, and company-wide meetings is required.