Job Profile Summary This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. In addition, this role focuses on performing the following Nurse Navigator duties: Focuses on the patient's needs and helps guide the patient through the healthcare system and works to overcome obstacles that are in the way of the patient receiving the care and treatment they require. A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs. The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. A senior level role that requires advanced knowledge of job area typically obtained through advanced education and work experience. Typically responsible for: managing projects / processes, working independently with limited supervision, coaching and reviewing the work of lower level professionals, resolving difficult and sometimes complex problems.Job OverviewThis position, in conjunction with Case Management, coordinates the transition of care from one health care setting to another which includes: inpatient, Home Health Care, Skilled Nursing Facility, Rehab facilities. Educates the patient and /or family regarding the patient's clinical condition, treatment, postoperative course, and the patient's role in recovery. Collaborates and communicates with a wide range of multidisciplinary providers with the goal of achieving an exceptional patient experience and the best possible patient outcomes.Job DescriptionMinimum Qualifications:1.Associate's degree in Nursing.2.Registered Nurse (RN) license.3. Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) certification.4. Three (3) years clinical experience caring for patients with a broad range of complex medical diagnoses.5. Valid, state-issued driver’s license and reliable transportation.Preferred Qualifications:1.Bachelor's degree in Nursing.2.Advanced Practice Registered Nurse (APRN)3.Eligible for state and federal controlled substances registration.4. Five (5) years clinical experience in home health, post-acute, or acute settings caring for patients for a broad range of complex medical diagnoses.5. Bilingual.Duties and Responsibilities: The duties and responsibilities listedbelow are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.1.Using effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions, promotes improved quality of care, prevents rehospitalization when possible and appropriate, and ensures appropriate transitions of care, including connections with community and acute services.2.Promotes cost effective nursing, medical and functional outcomes3.Promotes decreased lengths of hospital stays when appropriate with hospital case management transitions of care planning individualized to the patient.4.Assures appropriate levels of care are received by patients and involving family caregivers5.Improves transitions of care, identifies drivers of avoidable utilization of Emergency Department (ED) use and hospitalization. Diverts unnecessary ED admissions as appropriate.6.Utilizes tele-monitoring as a key modality in the care and monitoring of high-risk patients.7.Provides direct patient care/assessment as needed.8.Builds relationships Involved in transitions of care planning to steer patients to appropriate post-acute facility when initial transition to home is not successful (acute vs. subacute rehab, preferred SNF network, etc.)9.Monitors active hospital holds working collaboratively with respective liaison and case manager to ensure best transition of care.10.Partners with hospital and Care Management teams in the build and sustainability of innovative programs within a strong patient centered model.11.Provides appropriate consultation and referral to Case Management teams.12.Identifies appropriate alternative and non-traditional resources and demonstrate creativity in managing each case to fully utilize all available resources to meet medical and social determinants of health.13.Maintainsaccurate records of all interventions and providetimely verbal and written reports, as directed.14.Prepares regular management reports.15.Maintainsaccurate records of all communications and interventions.16.Ensures compliance within guidelines set forth by regulatory agencies (DPH, ERISA etc.) and demonstrates compliance with Home Health Foundation policies and procedures.17.Practices confidentiality principles set by the agency and federal HIPAA/HITECH guidelines.Physical Requirements:1. Prolonged, extensive, or considerable standing/walking.2. Lifts, positions, pushes and/or transfer patients and equipment.3. Considerable reaching, stooping, bending, kneeling, crouching.4. Frequent exposure to hazardous chemicals, sick patients, bodily substances, noise and possible exposure to radiation, lasers, electric shock, etc.5. Regularly exposed to the risk of bloodborne diseases and other transmissible infections.6. Contact with patients under wide variety of circumstances.7. Subject to varying and unpredictable situations.8. Handle emergency and crisis situations.9. Subjected to irregular hours.10. May have contact with hazardous materials.Skills & Abilities:1. Ability to effectively communicate with patients, families, physicians, and healthcare team.2. Knowledge and application of the nursing process to implement a nursing plan of care.3. Possesses and applies the skills and knowledge necessary to provide care to patients throughout the life span, with consideration of aging processes, human development stages and cultural patterns in each step of the care process.3. Skills and knowledge to provide care to the age groups of the population served including:Knowledge of growth and development; Ability to interpret age specific data and response to care; and Provide age appropriate communication4. Possessthe maturity, self-confidence, and ability to follow complex patient management plans in collaboration with medical staff.5. Ability to provide primary care for a caseload of patients according to practice guidelines and hospital policies, procedures and protocols. Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. Comprised of Tufts Medical Center, Lowell General Hospital, MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford, Care at Home - an expansive home care network, and large integrated physician network. We are an equal opportunity employer and value diversity and inclusion at Tufts Medicine. Tufts Medicine does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation by emailing us at .