Advanced Illness Nurse Navigator (Full Time)

About North Country Healthcare (NCH)

North Country Healthcare is a non-profit affiliation of four medical facilities, Androscoggin Valley Hospital, North Country Home Health & Hospice Agency, Upper Connecticut Valley Hospital, and Weeks Medical Center, located in the White Mountains Region of New Hampshire. NCH includes numerous physicians and medical providers at multiple locations. This leading comprehensive healthcare network which employs hundreds of highly-trained individuals delivers integrated patient care through three community hospitals, specialty clinics, and home health and hospice services. NCH remains committed to the health and well-being of the communities we serve. As a leader in a management position this role emphasizes advancing High-Reliability Organization (HRO) principles, embedding a culture of safety, accountability, and consistent high performance.

POSITION SUMMARY

Under the direction of the clinical leadership the Advanced Illness Nurse Navigator oversees the Home-Based Advanced Illness and Palliative Care Program and provides clinical expertise in care coordination for individuals who are homebound and living with advanced illness. The Advanced Illness Nurse Navigator collaborates closely with internal clinical teams, NCH-affiliated partners, and community providers to meet the evolving needs of patients with serious or advanced illness, while promoting comfort, quality of life, and goal-concordant care.

ESSENTIAL QUALIFICATIONS

Education:

• Associates of Science in Nursing (ASN) from an accredited institution. 
• Bachelor or Master’s degree in Nursing or Healthcare Management preferred.

• A combination of education and experience demonstrates the person has acquired the necessary competencies required for the position.

Licensure:

• Current Registered Nurse (RN) license in the state of practice
• Valid and maintained driver's license with up-to-date insurance policy on record.
• Association* accredited course in Basic Life Support (BLS) (for clinical staff), or Heartsaver CPR AED (for nonclinical staff), and renewal on a regular basis, with up to a three-month grace period after the expiration date.

Skills:

• Knowledge, skills, and abilities necessary to perform each essential function satisfactorily.
• Clinical expertise in palliative, hospice, or home care, or community-based care.
• Ability to serve as a liaison and program champion.
• Care coordination and case management skills.
• Strong interpersonal skills for relationship-building and collaborating with providers.

Work Experience:

• Three years in palliative, hospice and/or home care preferred, or experience in community-based care.
• Access to an operable, insured motor vehicle and valid driver’s license with acceptable record of safe driving practice is required.

ESSENTIAL FUNCTIONS

1. Provide consultations and program informational sessions in the home, inpatient, outpatient, or Assisted Living Facility settings, as well as community resource centers and other referral partners.
2. Provide physical and emotional symptom assessments on an ongoing basis.
3. Create plans of care that align with the patient’s goals.
4. Conduct medication review and education on an ongoing basis.
5. Provide advance care planning support.
6. Coordinate care with primary care physicians (PCP), specialists, Home Health, Hospice, Spiritual Care, and Social Work.
7. Assess caregivers and their roles as well as readiness, and create education and support plans.
8. Provide early hospice education.
9. Serve as a clinical liaison.
10. Case manage patients who are on the program.
11. Manage program referrals.
12. Triage for Home Based Advanced Illness and Palliative Care Program.
13. Build relationships with providers, serving as a liaison.
14. This position requires travel.

NON-ESSENTIAL FUNCTIONS

1. Performs additional duties as assigned.
2. Adheres to facility Values, Service Excellence and Standards of Excellence.