Registered Nurse | Care Continuum Navigator | Part Time

Care Continuum Navigator | Part Time
32 hrs. biweekly, 11am - 730pm, Weekend Option Available

The Care Continuum Navigator (Registered Nurse) plays a vital role in ensuring patients receive coordinated, patient-centered care across the healthcare continuum. Working collaboratively with the Emergency Department (ED), Inpatient Care Management, physicians, primary care providers, post-acute care facilities, and community organizations, this role focuses on improving outcomes for high-risk patients by addressing medical, behavioral, and social determinants of health.

The Care Continuum Navigator identifies patients with frequent or potentially avoidable emergency department visits and hospitalizations, assesses the underlying causes driving healthcare utilization, and develops individualized care plans that promote health, independence, and appropriate use of healthcare resources. This position serves as a patient advocate and care coordinator, helping patients and their caregivers navigate complex healthcare systems while connecting them with the services and support needed to achieve their health goals.

Success in this role is measured through improved patient outcomes, reduced avoidable hospital utilization, enhanced care coordination, and achievement of established quality performance metrics.

Key Responsibilities

Collaborate with Emergency Department and Inpatient Care Management teams, physicians, primary care providers, skilled nursing and assisted living facilities, and community agencies to coordinate seamless transitions of care.
Identify high-risk, rising risk, and Multi-Visit Patients (MVPs) with potentially avoidable emergency department visits or hospital admissions.
Conduct comprehensive assessments to identify clinical, behavioral, social, and environmental factors contributing to healthcare utilization.
Develop individualized, patient-centered care plans in partnership with patients, families, caregivers, and interdisciplinary healthcare teams.
Coordinate care across inpatient, outpatient, post-acute, and community settings to support continuity of care and improve patient outcomes.
Facilitate discharge planning from the Emergency Department by connecting patients with appropriate follow-up care, community resources, and support services.
Partner with outpatient care management teams and community organizations to address barriers to care and reduce unnecessary hospital utilization.
Advocate for patients while promoting safe, effective, and appropriate care in the least restrictive setting.
Monitor patient progress and evaluate the effectiveness of care coordination interventions using established quality metrics and outcome data.
Maintain accurate documentation and ensure compliance with organizational policies and regulatory requirements.

Qualifications:

Education - Associates Degree in Nursing required. Bachelor's of Science in Nursing preferred.

Experience - ASN with a minimum 3 years acute care experience and/or combined relevant experience in acute care Utilization role, SNF, or community health setting, or BSN with at least 2 years of acute care experience and/or combined relevant experience in acute care, utilization role, SNF, or community health setting.

Licensure/Certification - Current license to practice as Registered Nurse in the State of Maryland, or if resident of a state that participates in Nurse Multi-State Compact agreement, holds Registered Nurse License from that state that is designated as "Compact" or "Multi-State Privilege" using primary source verification and provides additional documentation as required by the Maryland Board of Nursing. RN License from a compact state with a designation of "Single State" does not meet the requirement and nurse must obtain a Maryland license. Care/case management certification required in 5 years of employment from an accrediting body.

Knowledge/Skills/Abilities - Knowledge of care management principles, professional practice standards, and health and public policy. Excellent clinical, interpersonal, and communication skills. Must be able to work collaboratively with other healthcare professionals as well as independently. Experience with coaching while working with the chronic, complex population. Must have knowledge of evidenced based practices, in depth knowledge of disease processes, and knowledge of community resources. Must be proactive, assertive, and possess creative problem-solving skills. Experience in managed care, medical home or integrated care management environment is preferred. Must be proficient in computer skills, internet, information technology and electronic medical record use.

Caring for Our Team
We offer a comprehensive benefits package to support our employees' well-being and professional growth. Benefits include health, dental, and vision insurance available starting the 1st of the month following date of hire, along with life insurance, & short and long-term disability coverage. Paid Time Off begins accruing from day one, and we also provide a 401k plan, an education assistance program, and an employee assistance program. Additionally, employees working evening, night, or weekend shifts may be eligible for a shift differential, adding even more value to your role.

Happy to Help

At Meritus, we believe in a collaborative and caring work environment. Interactions are an opportunity to learn, listen and to be there for one another. Therefore, we provide warm welcomes, hospitality-driven closures, and are always Happy to Help.

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Provides initial assessment and reassessments according to current organizational and department standards for Assessment of Patients and Nursing Assessment and documents according to policy. Anticipates potential changes in patient’s condition and responds appropriately. Anticipates needs based on assessment findings and proposed procedure or course of care. Ensures an effective plan of care for assigned patients based upon the standards for planning and providing care. Initiates individualized plan of care using nursing diagnosis based on identified patient needs and includes all available resources, e.g., family, caregivers, other disciplines and community agencies. Efficiently organizes and prioritizes patient care and seeks assistance when necessary in order to meet the needs of individual patients. Actively participates in development of standards of care according to departmental, organizational, professional or regulatory standards. Implements plan of care in compliance with hospital and nursing policies in accordance with all appropriate standards. Completely and accurately implements and documents nursing interventions and patient response. Communicates pertinent information to patient and members of the health care team in a concise and timely manner utilizing an interdisciplinary approach. Assures that the patient/family are updated regarding the status of the patient and any changes in the patient or plan of care as they evolve. Demonstrates flexibility in giving and receiving patient assignments on the department and hospital-wide based on skill mix of the staff available and patient care demands. Evaluates nursing care, which includes tools and equipment related to patient care. Reviews, evaluates and documents effectiveness of interventions, making modifications as needed on the plan of care. Evaluates new and existing equipment, policies, procedures and programs. Anticipates patient’s response to interventions and collaborates with patient/family and health care team to revise treatment plan accordingly. Identifies variances from expected outcomes and makes appropriate recommendations. Provides patient/family education Assesses patient/family for: Current knowledge of health status, condition or disease process; barriers to learning; readiness, willingness and ability to learn Cultural, religious, financial and patient preference implications related to learning. Identifies learning needs and establishes goals using standardized or individualized teaching plans. Implements the plan through direct, interactive teaching with additional use of teaching aids and materials as appropriate. Evaluates effectiveness of teaching. Communicates patient/family progress toward learning goals and need for follow-up to other nurses and health care disciplines. Integrates discharge planning and referral into the teaching process. Documents teaching per policy. Independently offers support to less experienced staff to aid in patient/family teaching. Demonstrates professional expectations as evidenced by: Incorporates suggestions for self-development and/or performance into daily practice. Meets all requirements of clinical ladder level. Actively engages in department efforts to promote retention of staff and provide for a high level of employee morale. Utilizes supplies, equipment, and technology to ensure quality of patient care. Floats to other nursing units in the hospital as requested Demonstrates leadership/accountability qualities. Consistently utilizes communication style that sets department tone for positive professional behavior. Promotes meaningful focused communication between all members of the healthcare team as appropriate. Encourages professional interactions between ancillary healthcare givers, including physicians. Demonstrates effective delegation skills as they pertain to nursing staff in the delivery of safe nursing care and communication to peers. Demonstrates effective precepting and mentoring skills for RN’s and ancillary staff. Adheres to program policies and participates in effective department orientation. Demonstrates accountability for the following which includes but is not limited to: Reviewing Quality Assurance report/data for accuracy and completeness according to departmental standards. Contributing to the evaluation/auditing process for CNA’s, Technicians, and peers, etc. Must complete all Hospital wide and Department specific competencies. Required Knowledge, Skills and Abilities: Clinical competency in their departmental area of practice. Ability to use technology and equipment to perform job duties. Effective interpersonal and communication skills. Effective use of proper body mechanics when handling patients, supplies and equipment. Ability to handle a physically demanding environment. Skills and abilities to perform all job description duties according to the age specific patient population served by their department. Ability to meet the requirements annually of the FH Clinical Ladder. Ability to keep patient and employee information confidential Competency in operating equipment required to meet patient care needs. Minimum Education, Training, and Experience Required: Eligible for or currently licensed as a Registered Nurse in State of Maryland or compact state. Associates degree in Nursing required; Bachelors of Science in Nursing preferred or willing to obtain within 5 years of employment Certified in Cardiopulmonary Resuscitation (CPR). BLS certification is required of ALL nurses within 90-days of hire. The following certifications are required for the nursing units specified. Each certification must be completed within 1 year of hire. § 2C (Oncology/Thorasic) – Chemotherapy § 4B, 4A, 4G, 2G (Telemetry) – ACLS § L&D, OB/OR – NRP, C-EFM w/in 3 years § Family Center – NRP § NICU – NRP § ICU – ACLS § Peds/Peds ED – PALS § OR – ACLS § Cath Lab – ACLS § PACU – ACLS § ENDO – ACLS § Pre-Op – ACLS § Emergency Dept – ACLS, PALS, Base Station Patient Contact Must demonstrate and maintain current knowledge and skills in providing appropriate care/contact for patients in the following age groups * This would be based on designated patient population for each nursing department. X Neonate (0 thru 30 days) X Infant (31 thru 12 months) X Child (13 months thru 12 years) X Adolescent (13 years thru 17 years) X Adult (18 years thru 65 years) X Geriatric (66+ years) Physical Demands: Medium-Heavy Work – Lifting up to 100 pounds on an infrequent basis (less than one lift every three minutes) and/or carrying up to 50 pounds while walking. Pushing or pulling up to 115 pounds infrequently or greater than 115 pounds occasionally (no more than once per hour). Ergonomic Risk Factors: Repetition : Repeating the same motion over and over again places stress on the muscles and tendons. The severity of risk depends on how often the action is repeated, the speed of the movement, the required force and muscles involved. Forceful Exertion : The amount of physical effort required to perform a task (such as moving patients) or to maintain control of equipment or tools. The amount of force depends on the type of grip, the weight of an object or person, body posture, the type of activity and the duration of the task. Awkward Posture : Posture is the position your body is in and its effect on the muscle groups that are involved in the physical activity. Awkward postures include repeated or prolonged reaching, twisting, bending, kneeling, squatting, working overhead with your hands or arms, or holding fixed positions. Contact Stress : Pressing the body hard on sharp edges can result in placing too much pressure on nerves, tendons, and blood vessels. For example, using the palm of your hand to hit or stick objects can increase risk of musculoskeletal disorders. Working Conditions: Bloodborne Pathogens Exposure Risk: Category A – WILL have exposure to blood or body fluids. Exposure to infectious diseases, hazardous materials and highly technical and heavy equipment. Reporting Relationship: Reports to Department Manager. Also receives supervision from Director or Hospital Supervisor. Disclaimer: The content of this document reflects the general duties, responsibilities, minimum skills, abilities and competencies necessary to perform the essential functions of the job and should not be considered as an exhaustive detailed description of all the work requirements of the position. Schedule: Part time position 48 hrs per pay period 7p-7:30a with weekend and holiday rotation. 8hr on call per schedule Caring for you as you care for the CommUNITY Frederick Health offers a comprehensive and affordable benefits package. Health, Dental and Vision insurance are offered the 1st of the month after 30 days of employment to all employees hired to work at least 20 hours per week and we offer multiple plans to best meet your and your family's needs. Life insurance, Short-Term Income Replacement and Long-Term Disability are employer paid for eligible employees. Frederick Health offers a robust Paid Time Off program for eligible employees. Our 403B retirement plan helps you save for your retirement and includes an employer match to eligible employees. All employees have access to free financial planning sessions. We also offer an educational assistance program to support your education goals as well as an employer paid Employee Assistance Program. Pay is based on experience, skills and education. If position is part-time, salary will be pro-rated based on scheduled hours. The pay range may also vary within the stated range based on specialty if applicable. Non-Exempt positions may have shift differential and/or Overtime paid, if applicable. Pay range: $36.07/hr Min - $55.17/hr Max