The Oncology Nurse Navigator is accountable for navigation and coordination of care utilizing evidenced-based clinical pathways for oncology patients along the continuum of care for their cancer from diagnosis through treatment to survivorship care. They will provide longitudinal comprehensive nursing care to a designated case of oncology patient. They will have primary nursing responsibilities for the coordination of care, symptom management and education of patients and families. This position will work in collaboration with all members of the healthcare team to achieve the best possible outcomes for the patient.
1. Manage, develop, implement, and evaluate initial patient plan of care following clinical pathways in collaboration with the Oncology Physician, and the health care team, to determine the effective utilization of resources and outcome achievement.
· Obtain, review, and scan outside patient records for new newly referred oncology patients. Determine need for further diagnostic work-up; communicate and coordinate necessary tests or procedures to the patient and the healthcare team. This includes coordination of provider orders from both inside and outside the system.
· Coordinate simple and complex patient care issues in conjunction with other parts of the healthcare system, working inter-departmentally.
· Determine timeliness/time appropriateness of appointments.
· Ensures effective and appropriate utilization of resources and efficient patient throughput along continuum of care.
· Document interim progress notes reflecting coordination of care/services.
· Intervene when the clinical pathway is not being followed, either due to patient constraints or ineffective follow-through.
· Collaborates with the healthcare team to make appropriate referrals to other healthcare settings and community resources.
· Provide triage services and symptom management to patients as needed, in-person and over the phone. Communicate symptomology to appropriate team members.
· Conduct toxicity checks/assessment on patients.
· Ongoing assessment of patients for unmet social needs with appropriate referral and communication to social services, community resources, etc.
2. Monitor continuity of care and expedite delivery of services to move patients through the system effectively.
· Develops, implements and updates clinical care pathways for Specialty Care with Practice Manager, Physician, and healthcare team.
· Identify and document variances from pathways and collaborate with the health care team in relation to patients' progress.
· Assist with care coordination between radiation and medical oncology departments.
· Collaborates with staff in the different departments on clinical and operational issues to ensure timely and appropriate patient throughput in the healthcare system.
· Collaborates with the health care team as needed to facilitate patient's care across the healthcare continuum.
· Ensure that patient and family have received appropriate education and instructions in collaboration with health care team. This includes patient teaching on the disease, treatment options, procedures, and chemotherapy regimens and side effects.
· Assess and coordinate patients receiving radioactive pharmaceuticals and oral chemotherapies.
· Facilitate and/or conduct patient, family, and team conferences and rounds to develop and monitor a plan of action as necessary.
· Appropriately assess and refer patients to support services, including social services, palliative care, survivorship, home health, hospice, etc.
· Conduct Advance Care Planning discussions with patients and family members.
· Aggregate data to identify patterns/trends of screening patients and delivery of care, report the data to appropriate administrative bodies, and facilitate change when necessary.
· Document all care appropriately in the patient EMR.
· Attend weekly tumor board meetings and other coordination meetings as needed to assist with the coordination of patient care and/or community support.
3. If the role includes survivorship navigation the essential functions will include duties which assist coordination of care for patients in the survivorship program.
· Reaches out to patients who are appropriate for survivorship program to inform them what the components of the program are and encourage them to take part in it.
· Assists and supports patients who are referred to survivorship to coordinate for the initial survivorship visit or other survivorship services.
· Prepares individual treatment summaries and care plans for patients.
· Member of survivorship task force for Oncology Service Line.
· Involved in data collection for survivorship program.
· Coordinates and communicates with other departments outside the Oncology Service Line who provide service for oncology patients to encourage knowledge and utilization of survivorship program.
Demonstrate Standards of Behavior and adhere to the Code of Conduct in all aspects of job performance at all times.
· Current Washington State Nursing License.
· Current BLS Health Provider card.
· 3 years of clinical experience.
· Working knowledge of case management with clinical pathways.
· Knowledge or variance identification/reporting and process improvement.
· Ability to effectively communicate with patients and health care team.
· Working knowledge of team building and facilitation skills.
· Competent in basic computer skills.
· Ability to work independently and perform role with minimal guidance.
· Case Management experience/certification preferred.
· Oncology experience preferred.