Community-Based Nurse Navigators

The Community Based Nurse Navigator (CBNN) is accountable for the high-risk patient population of Tandigm PCPs within our 5-county (Philadelphia, Montgomery, Chester, Bucks, Berks Counties) within Philadelphia, PA territory. The successful candidate takes on 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. 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.

Essential Functions

  • Consistently exhibits behavior and communication skills that demonstrate Tandigm Health commitment to superior customer service, including quality, care and concern with each and every internal and external customer.
  • Provides complex care planning to high-risk patients in the community, meeting with them face to face before, during, or after PCP visits, according to established program protocols and policies.
  • Accepts responsibility for patients’ Transitions of Care, coordinating provisions for discharge from facilities including follow-up appointments, home health, social services, transportation, etc., in order to maintain continuity of care.
  • Coordinates and facilitates communications between all patient settings, including ambulatory, acute care, short stay, skilled nursing, palliative care and hospice.
  • Conduct follow-up telephonic care calls to patients and families, as required.
  • Promotes patient self-management, educating patients on disease, medication, access to care, self-care support, to improve clinical outcomes and increase patient self-efficacy.
  • Reviews /triages PCP referrals to determine program and service needs of patients referred.
  • Collaborates with the patient, family or caregiver, and the Tandigm PCP and office staff to help develop a POC customized to patient goals and needs.
  • Implements POC in accordance with established policies, prioritizing patient care needs and meeting with patients, patients’ family and caregivers as needed to discuss care and treatment plan.
  • Maintains effective relationships with patients and families, PCPs and office staff, other providers, and community based agencies, facilitating interdisciplinary team meetings regularly.
  • Consults regularly with the PCP, Tandigm Medical Director, Manager, and other team members to ensure that the POC remains relevant, appropriate, and responsive to changing patient status and/or goals.
  • Leverages all available patient information available, including but not limited to PCP and hospital EMRs, maxMC, Athena, departmental databases, etc.
  • When appropriate, conducts on-site or telephonic prospective, concurrent, and retrospective review of active patient care to evaluate goal progression and timely discharge
  • When appropriate, coordinates treatment plans and discharge expectations and discusses DPA and DNR status with attending physician
  • Participates actively in clinical rounds and/or case review meetings with Tandigm Medical Director, reviewing panel of high risk patients, including prospective and newly enrolled patients.
  • Demonstrates a thorough understanding of the cost and quality consequences resulting from care management decisions
  • Maintains accurate and complete records, documents all care rendered, pertinent patient information, all communications, and all care management decisions in appropriate databases.
  • Initiates and oversees data entry into IS systems of all patients within the parameters of care management policies and procedures.
  • Provides accurate information to patients and families regarding community resources, referrals, and other related issues.
  • Uses, protects, and discloses Tandigm patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
  • Performs additional duties as assigned.


  • A passion for community based, team oriented population health that is PCP led, patient centered, and focused on clinical and quality outcomes
  • Excellent interpersonal communication skills and the ability to represent Tandigm Care Delivery Support in a community setting
  • Proficiency in computer skills, including Microsoft Office, EMRs and other clinical databases; accuracy and attention to detail; ability to multi-task, i.e., chart clinical data during patient encounters.
  • Pennsylvania RN license in good standing
  • Reliable transportation with valid driver’s license and active automobile insurance
  • Basic Life Support for Healthcare providers or CPR/AED for the Professional Rescuer


Position requires a Bachelor’s degree from a four-year college and/or a professional certification requiring formal education beyond a two-year college; Must be a graduate of an accredited school of nursing.



  • Minimum of 5 years of nursing experience in an acute care setting.
  • An additional 2 years of nursing experience in an ambulatory care or homecare setting


  • Case management, utilization review, discharge planning, or nurse navigation experience.
  • Experience working in a primary care physician office.

Knowledge, Skills & Abilities

  • Customer-service oriented; responsive and respectful to colleagues, clients, patients, and providers.
  • Ability to make sound, independent judgments and act professionally under pressure.
  • Ability to effectively communicate and collaborate with physicians, other providers, patients, families, and ancillary staff.
  • Knowledge of current best practice standards of patient care.
  • Thorough understanding of, and compliance with, RN scope of practice in the Commonwealth of Pennsylvania.
  • Excellent communication skills; ability to represent the organization to internal and external stakeholders with skill and confidence.
  • Organized, detailed, and proactive; responds to requests in a timely and efficient manner.
  • Collaborative and resourceful; functions successfully in a team environment as well as independently.
  • Computer literate with proficiency in Microsoft Office suite of programs.
  • Ability to type 45 wpm.
  • Knowledge of medical terminology, CPT and ICD-10 coding.
  • Knowledge of IPA/group internal processes and contractual agreements.
  • Working knowledge of HMO/managed care/health plan.
  • Manual dexterity to use/handle equipment and instruments.
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