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Population Health Nurse Navigator, Care Transition Clinic - Full-Time, Days

Be a part of a world-class academic healthcare system at UChicago Medicine as a Population Health Nurse Navigator supporting our Care Transition Clinic at our Hyde Park clinic. This position is a 100% onsite opportunity. You will need to be based in the greater Chicagoland area.

Under the direction of a faculty sponsor and in collaboration with the program support team, coordinates population health care needs for patients and potential patients in the community across the care continuum. Acts as a clinical liaison for patients and potential patients, across medical service, clinical departments, and locations. Assesses clinical, emotional, spiritual, psychosocial, financial, and other patient needs. Evaluates and manages patient care gaps and assists in the integration of care across departments to address those gaps.

Based out of the Call Center, under the direction of a faculty sponsor and in collaboration with the program support team, coordinates population health care needs for patients and potential patients in the community across the care continuum. Acts as a clinical liaison for patients and potential patients, across medical service, clinical departments, and locations. Assesses clinical, emotional, spiritual, psychosocial, financial, and other patient needs. Evaluates and manages patient care gaps and assists in the integration of care across departments to address those gaps.

Essential Job Functions

  • Acts as liaison for patients, families and their multidisciplinary clinical team to address the population health needs of our patients and the community

  • Assesses clinical, emotional, spiritual, psychosocial, financial, and other patient needs.

  • Facilitates resolution to patient care gaps and monitors follow up/completion by both proactively reaching out to patients and addressing direct phone calls and messages from patients.

  • Educates/reinforces education with patients and families on population health measures, specific disease processes relevant to those measures, and the steps patients can take to mitigate, treat, and properly diagnose those disease processes based on the multidisciplinary care plan.

  • Participates in relevant quality workgroups to assist in the development of patient education materials, clinical pathways, and workflows to improve patient compliance with population health measures.

  • Triages, coordinates, and orders appropriate patient testing using established protocols and facilitates record gathering process if testing performed outside UCM.

  • Serves as primary point of contact for patients discharged from the hospital to address questions and patient care needs to prevent readmission or an emergency room visit.

  • Directs patients and families to available community resources and support services. Assists patients to overcome barriers to care, i.e. transportation, financial counseling, etc.

  • May be responsible for direct patient care

  • Performs other duties assigned.

Required Qualifications

  • Registered Nurse with a current Illinois license.

  • Bachelor of Science in Nursing degree (BSN)

  • Minimum of two years clinical nursing experience with demonstrated clinical competence in patient care, teaching and management of patients.

  • Must have general computer and phone skills and be adaptable to changing working situations and work assignments.

  • Excellent interpersonal skills required, with specific ability to communicate effectively with patients, family members, and physicians.

Preferred Qualifications

Masters degree in Nursing

    Position Details

    • Job Type/FTE: Full-Time (0.6 FTE)
    • Shift: Days - 8 am – 5:30 pm
    • Work Location: Onsite - DCAM Hyde Park
    • Unit/Department: Care Transition
    • CBA Code: Non-Union
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