Nurse Navigator-Internal Medicine - Infectious Disease

USA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community.

USA Health is changing how medical care, education and research impact the health of people who live in Mobile and the surrounding area. Our team of doctors, advanced care providers, nurses, therapists and researchers provide the region's most advanced medicine at multiple facilities, campuses, clinics and classrooms. We offer patients convenient access to innovative treatments and advancements that improve the health and overall wellbeing of our community.

To provide dedicated clinical oversight to a specific vulnerable patient population within a department. This role serves as the intermediary between multiple service lines and pathways to ensure the patient care plan remains intact and patient centered throughout the disease process and their care transitions. Assists the provider in the medical management of outpatients in the clinic; participates in direct patient care activities including but not limited to assessments, vital signs, specialty specific procedures/testing, injections, wound care, and phlebotomy; manages calls and messages from patients, families, other health care providers and pharmacies to ensure patient’s needs, questions and treatments are addressed in a timely fashion; communicates with overseeing provider to receive orders for prescriptions, medical equipment, home health/hospice etc. and obtain insurance authorizations as required; serves as the primary contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources; provides education and information to the patient and caregiver(s) related to their ongoing plan of care including current medications (including side effects), diagnostic schedules, follow-up schedules, and symptom management; documents patient teaching including family and others, based on assessment of needs and respond to patient request; assist in coordination of care for the patient and caregiver(s) and provides emotional support; cultivates and supports primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals; works across health care disciplines to assist in coordinating patient tests, procedures, appointments, and treatments, and assist patients in overcoming barriers to care including, but not limited to, transportation, financial counseling, and referrals; refers patients for supportive care services including nutritionists, social workers, counselors, and financial counselors; establishes referral processes for each clinical area mentioned above; monitors the patient through their care in the system including in working with the patient and caregiver(s) while inpatient to ensure the plan of care is clear and continues after discharge; rounds on patient as needed for plan of care update and education purposes; continuously educates patient and caregivers during any transitions of care including but not limited to inpatient/outpatient stay, procedure/surgical care, rehab admission or discharge, or other specialty clinic care; works with providers to monitor patient population to analyze care plans, resources provided, and find opportunities to develop new tools or care pathways to serve the patients; other related duties as required; regular and prompt attendance; ability to work schedule as defined and additional hours as required.

EO Employer – minorities/females/veterans/disabilities/sexual orientation/gender identity.