Nursing Facility Attending Service - Nurse Navigator

Virginia Commonwealth University Health Systems
United States, Virginia, Richmond
Jun 09, 2025
The Nurse Patient Navigator functions as a Nurse Patient Navigator and serves as an advocate, interpreter, educator and counselor for a group of patients. The Nurse Patient Navigator manages the care of assigned patients in collaboration with a multidisciplinary team to ensure high quality and comprehensive healthcare and ancillary services. The Nurse Patient Navigator serves as the single point of contact to assigned patients and caregivers. The Nurse Patient Navigator remains a support system to patients and caregivers throughout the patient's treatment. The Nurse Patient Navigator uses clinical/nursing knowledge and skills in the performance of job responsibilities. The VCU Health Nursing Facility Attending Service (NFAS) back-office support is being expanded to add a critically important Nurse Patient Navigator to work alongside Care Coordination Assistants and nine providers in this thriving mobile medical practice serving post-acute patients discharging from VCU Medical Center. Started in the mid-1990s, and expanded over the last decade, the NFAS is a "SNF-ist" program which is dedicated to improving patient care, enhancing continuity, and avoiding costly hospital readmissions from the skilled nursing rehab domain. The NFAS practices with a patient-centered approach, actively participating in the residents' recovery and stabilization by working directly with them and their families. After hours on-call is covered x 365 days by the VCU Geriatric Medicine Division physicians with support from PAC Triage RNs in the VCU Continuum Integration Center (CIC). The NFAS is comprised of five Physicians and four APPs who cover the nine area nursing homes in the VCUMC preferred SNF network across the Richmond metro region. The program is designed to cover >90% of the VCUMC placements in SNF care, and the team is currently achieving that goal. The team also provides long term care to VCU patients who reside in the area nursing homes in the VCU preferred network. Dr. Christian Bergman is the medical director and section chief for the NFAS. https://www.vcuhealth.org/find-a-provider/profile/carl-bergman The Nursing Facility Attending Service has expanded to serve VCUMC hospital discharges that have become more timely and also more complicated. With this growth in demand and complexity, the NFAS Providers are managing care coordination needs daily. The goal of the augmented back-office support and Nurse Navigator role is to reduce/eliminate non-provider effort from providers' workdays, and for all staff to work to the top of their licenses. In essence as part of the NFAS interdisciplinary team, the Nurse Navigator aims to improve the overall quality of care for patients in partner SNFs by providing specialized expertise, personalized attention, and coordinated care efforts. Select unit specific duties and goals include: The NFAS and the Nurse Navigator practice Patient-Centered Care: ensuring that patients receive care that is individualized and focused on their needs. NFAS Nurse Navigator is trained to address the specific needs of patients in SNFs, which includes patients who are recovering from illnesses, have chronic conditions, and require rehabilitative or geriatric care. The NFAS Nurse Navigator is a valuable member of the interdisciplinary team, playing a vital role in improving patient care, outcomes, and the overall experience of patients and their families in the SNF (or long-term care) setting. The NFAS Nurse Navigator serves as a critical point of contact to inpatient discharge planners and providers, NFAS providers, and assigned SNF and LTC patients/families/caregivers, as needed. They ensure effective communication among all providers involved in a patient's care, leading to more cohesive and coordinated treatment. With the NFAS provider team, they improve the quality of life for patients and residents by providing personalized care plans, promoting patient engagement, and ensuring that residents receive continuous, high-quality care. They work with the interdisciplinary team (physicians, APPs, CCAs) to coordinate patient care and ensure a smooth transition to/from the SNF. They deliver improved patient outcomes by coordinating care and providing support to members of the care team. They serve as a consistent point of contact for VCU staff, patients and families, addressing concerns, providing updates, solving clinical problems. They play a crucial role in preparing patients for discharge, ensuring they have the resources and support they need to return home or transition to another level of care like VCU Home Health. A critical team-based care resource, they can help improve both provider and patient satisfaction. The successful candidate will have: Professional enthusiasm and commitment to patient and family experience Creative problem solving and critical thinking skills to support coordination of care Ability to plan, motivate and organize self, others and work in order to achieve objectives and targets. Exceptional interpersonal skills, with demonstrated ability to establish, maintain, and leverage positive, productive working relationships with individuals at all levels throughout an organization. Strong technical/computer skills with the ability to work in multiple applications and on various devices such as Microsoft Word, Excel, Teams, an electronic medical platform, a smartphone, and/or laptop. Determination to deliver outcomes and ability to overcome obstacles in order to move forward. Strong written, verbal and interpersonal communication skills with an acute ability to listen attentively and to communicate effectively throughout all levels of the organization. Group motivation, creativity and diplomacy. Highest-level customer service standards. *Strong patient educational skills. Licensure, Certification, or Registration Requirements for Hire: Current RN licensure in Virginia or eligible or compact state Licensure, Certification, or Registration Requirements for continued employment: Current RN licensure in Virginia AHA BLS Certification Specialty Nursing Certification in either Nurse Navigation or area of specialty within one year of hire in position Experience REQUIRED: Minimum of three (3) years of relevant clinical experience in nursing, patient education; case management and/or navigation Previous experience in specialty area Experience PREFERRED: Previous nurse navigation or leadership experience Experience within an academic, teaching hospital Education/training REQUIRED: Baccalaureate Degree in Nursing from an accredited School of Nursing Education/training PREFERRED: Master' Degree in Nursing from an accredited School of Nursing Independent action(s) required: Follows documented physician/licensed independent provider medical/treatment orders. Practices within the boundaries of the regulations governing the practice of nursing in the Commonwealth of Virginia. Practice is guided by the ANA Code of Ethics for Nursing and established national nursing practice standards. All practice is guided by and follows the VCUHS policies and procedures and established practice guidelines. Organizes and plans work with input from the patient/family with specific outcomes identified. Demonstrates use of sound clinical judgment based on nursing knowledge/experience. Supervisory responsibilities (if applicable): N/A Additional position requirements: Positions are primarily weekday work but may be expected to work into the evening or on the weekend, depending on assignment. May be required to go to all VCUHS locations. Age Specific groups served: As appropriate based on unit assignment Physical Requirements (includes use of assistance devices as appropriate): Physical - Lifting less than 20 lbs. Activities: Prolonged standing, Prolonged sitting, Frequent bending, Walking (distance), Climbing (steps, ladder, other), Reaching (overhead, extensive, repetitive): Repetitive motion Mental/Sensory: Strong recall, Reasoning, Problem solving, Hearing, Speak clearly, Write legibly, Reading, Logical thinking Emotional: Fast pace environment, Steady pace, Able to handle multiple priorities, Frequent and intense customer interactions, Noisy environment, Able to adapt to frequent change EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.