Job Description

• Establishes and revises the plan of care for appropriateness on anon-goingand timely basis as directed by the patient’s care team. Assists in the development of a comprehensive diagnostic/treatment plan related to the patient's needs, through interdisciplinary input and attendance at weekly meetings.
• Coordinates patient care activities and management of clinical data throughout all phases of patient care from initial referral to follow-up. Arranges for clinical services, evaluates clinical data, participates in clinical/ patient rounds, and triages clinical questions/ concerns to the appropriate members of the interdisciplinary team.
• Develops,coordinates, implements and evaluates educational programs/ projects for patients/caregivers, nursing staff and assigned members of the support staff. Serves as a preceptor for other coordinators. Provides educational sessions for patients/caregivers and other clinical staff throughout the Medical Center as appropriate.
• Demonstrates clinical competence in the assessment and intervention for patient, family, or significant other requiring emotional support, coping support and care for significant life changes. Coordinates support services within the health system and community to meet patient/family needs.
• Provides leadership in developing standards of care for patients undergoing new therapies, demonstrates knowledge and follows the approved protocol for specialized nursing care.
• Tracksvolume of referrals and transports, measures outcomes. Actively works to increase in the number of outpatient and inpatient referrals, procedures, and patient participation in various clinical and research programs and outreach activities.
• Consults with physicians and other health care professionals as indicated regarding patient care issues and quality of care issues related to patients. Supports the leadership and clinical teams by providing progress reports on patient care, local partnerships, and other quality measures. Actively participates in quality improvement measures and projects as requested and directed. Recommends, develops, and implements policy/protocol revisions and performance improvement activities based on current standards.
• Utilizes a systematic approach to assess educational needs in collaboration with all levels of nursing and medical personnel and evaluates the effectiveness and efficiency of educational programs. Collaborates throughout the Cedars-Sinai Health system (CSHS) in initiating and implementing educational programs.
• Independently coordinatespatient programs, projects and events with Nursing, medical center departments and communities across the health care continuum. Serves as a resource and consultant for educational programs throughout the Cedars-Sinai Health System.
• Establishes, coordinates and continuously evaluates supportive care planwith goals and interventions based upon treatment and individualpatient/caregiver needs, preferences, beliefs and values.
• Promotes/ facilitates research by facilitating inter and intra-departmental research, promotingcollaborative research and utilizing education and clinical research findings to design/ revise education programs throughout the Cedars-Sinai Health System.
• Actively works to create new transfer agreements with local hospitals, works to build new referral relationships with key physician groups and hospitals in Southern California.
• Coordinates and collaborates with other Nurse Navigators in various divisions and departments to effectively coordinate care of all identified patients.
• May represent the Medical Center at regional and national meetings/conferences.
• Performs all other duties as assigned.

• Call new patients in advance, meet them at consult and provide education in regards to surgery.
• The “point persons” to call for patient questions pre and post-op surgery. The NN’s see patients at their first post-op visit and not beyond unless the patient has complex needs.
• Attend multidisciplinary breast tumor board.

• Schedule all pre-testing for BMT patients prior to their transplant.
• Provide extensive education and see them prior to their admission for transplant. They do not follow these patient’s inpatient or post discharge after transplant.

• Call new patients in advance of their consult, see them at consult, provide support, education, ensure referrals are done (i.e. radiation), see patient on first day of their chemo and call them 24-48 hours after their first chemo.
• Hand-off to the practice RN who follows them throughout their continuum of care.
• Provide referrals to nutrition, social work and attend weekly interdisciplinary meetings.

• Work collaboratively with departments’ administrative staff to develop,manage, and produce all paper and electronic mailings, additional marketing collateral material and newsletters (where applicable) for the departments. This includes creating easy-to understand and informativepatient brochure/pamphlets and webpages about OBGYN and Pediatrics and their cutting edge technology, programs and research studies, electronic communication.
• Participate in the development of workflows, communication and education for administrative and clinical staff involved in transport, grand rounds etc. as needed with the Departments of OBGYN and Pediatrics leadership teams. Include in plan: targeted regions, targeted hospitals, targeted patient populations/procedures/surgeries, timeline, and goals for performance.
• Work with CSHS physicians and nurses to develop educational programs for other hospitals in coordination with Pediatrics department and Nurse Navigator/ Associate Directors.
• Establish new transfer relationships between CSMC and outside hospitals.
• Collaborate with Client Services to ensure referral process is followed.
• Attend and represent OBYN and Pediatrics in CME programs, symposia and community programs associated with CSMC and/or perinatal health.
• Attends and participated in simulations as indicated and requested to improve quality improvement processes.
• Meets with inpatient and outpatient leadership teams to provide updates, participate in leadership growth and development programs and coordinate leadership needs.

• Maintain the operations of the Maternal Transport Programs, and weekly perinatal interdisciplinary meeting
• Oversee service agreements between CSMC and transportation vendors for proper communication of billing and revenue for CSMC and potential hospital partners.
• Coordinate enrollment to OBGYN and Pediatric research studies available to patients being transferred to CSMC.
• Transition current transfer agreements to transport agreements as appropriate.
• Cultivate existing relationships with hospitals with existing transfer agreements with CSMC by assessing educational needs and scheduling regular visits (with or without faculty).
• Provide timelypatientfollow-up reports for referring hospitals and providers.
• Ensure all necessary and required information and documentation is available for hospital transport partners (collaborate with clinical teams as needed).
• Ensure and report out on a system/process to measure success and growth of programs (visits, procedures, surgeries etc.).
• Develop and implement strategies that will maximizesynergies, and thus, referrals among hospital partners.
• Manage the Telemedicine service agreements currently in placebetween CSMC and Telemedicine vendors and ensure revenue stream for CSMC to telemedicine activities.
• Facilitate with the Transfer Center the referral and transfer of patients requiring higher level of care into CSMC.
• Coordinate and participate in teaching opportunities for clinical staff of referring hospitals.

• Collaborates to problem solve and make decisions to achieve desired outcomes
• Establishes effective working relationships with cross-functional team(s)
• Shares knowledge, time and expertise to assist other members of the team
• Ensures practices and procedures are inclusive of interpersonal and cultural diversity
• Identifies and responds appropriately to both internal and external customer needs utilizing available resources

Qualifications

• Bachelor of Science in Nursing required

• Current, unrestricted California RN license required
• Professional Certification in area of specialty required within one (1) year of hire

• A minimum of 3 years of nursing experience in an acute care setting (transplant, cancer)
• Experience with program development and implementation of navigator programs preferred