Nurse Navigator

Encore Village is currently hiring for a Nurse Navigator. The Nurse Navigator is a licensed Registered Nurse responsible for providing clinical coordination, care navigation, and continuity of care for residents living in Independent Living and throughout the continuum of care. This role serves as a clinical resource and liaison for residents, families, physicians, and internal and external healthcare providers, ensuring safe, appropriate, and timely transitions between levels of care.

This role is housed within the community’s Resident Success Department and serves as the department’s clinical and nursing-focused resource, supporting resident health, care coordination, and transitions across the continuum of care.

The Nurse Navigator focuses on clinical assessment, care coordination, transition management, and provider communication, working closely with internal departments and external healthcare partners. The ultimate goal of this role is to support residents in maintaining the highest appropriate level of independence and health, while proactively identifying changes in condition, coordinating services, and preventing avoidable hospitalizations.

Essential Job Functions / Responsibilities

Clinical Care Coordination & Navigation

• Serves as the primary clinical point of contact for Independent Living (IL) and Assisted Living (AL) residents and their physicians regarding health status changes, care needs, and coordination of services.
• Performs ongoing clinical assessments, monitoring residents for changes in condition that may require intervention, additional services, or transition to a higher level of care.
• Ensures residents are appropriately placed within the continuum of care, including:
• Independent Living (IL)
• Assisted Living (AL)
• Assisted Living Memory Care (AL MC)
• Short-Term Rehabilitation Skilled Nursing (STR SNF)
• Long-Term Care Skilled Nursing (LTC SNF)
• Coordinates transitions of care between levels, ensuring continuity, communication, and safe clinical handoffs.

Physician & Provider Collaboration

• Acts as a clinical liaison between residents, families, physicians, and internal clinical teams.
• Facilitates timely communication regarding changes in condition, new diagnoses, treatment plans, and follow-up needs.
• Assists residents in understanding physician recommendations and treatment plans.
• Supports coordination of physician appointments, labs, diagnostics, and follow-up services as clinically indicated.

Internal Service Referrals & Care Pathways

• Initiates and coordinates referrals to internal Encore Village services, including:
• Home Care (available to IL and AL residents)
• Outpatient Therapy (available to IL and AL residents)
• Short-Term Rehabilitation, Skilled Nursing
• Long-Term Care, Skilled Nursing
• Collaborates with clinical leadership to ensure referrals align with resident needs, payer considerations, and regulatory requirements.
• Supports discharge planning and re-entry into Independent Living following rehabilitation or skilled stays.

External Agency Oversight & Tracking

• Maintains oversight of external healthcare agencies and providers practicing within the community.
• Tracks required documentation, credentials, and compliance for all outside agencies.
• Develops and maintains relationships with external partners to support resident outcomes and care coordination.

Risk Reduction & Clinical Oversight

• Reviews incident reports, emergency call notes, and health-related events to identify trends and opportunities for risk mitigation.
• Collaborates with interdisciplinary teams to implement proactive strategies to reduce hospitalizations, falls, and clinical deterioration.
• Maintains emergency medical information and ensures accuracy and confidentiality.

Interdisciplinary Collaboration & Meetings

• Participates in relevant clinical and operational meetings related to resident care and transitions.
• Works collaboratively with nursing leadership, therapy, admissions, home care, and Resident Success to support holistic resident outcomes.

Documentation & Compliance

• Maintains accurate clinical documentation and care coordination records.
• Ensures compliance with state regulations, professional nursing standards, and organizational policies.
• Develops and maintains lists of internal and external clinical resources aligned with community needs.

Program Development & Education

• Supports health education initiatives focused on prevention, chronic disease management, and healthy aging from a clinical perspective.
• Assists in the development of nursing-driven protocols, workflows, and best practices related to care navigation and transitions.

Position Qualifications

• Current RN license in the state of practice (required).
• Graduate of an accredited school of nursing.
• Three to five years of clinical experience in long-term care, post-acute care, home health, care management, or related healthcare setting.
• Strong clinical assessment and care coordination skills.
• Excellent communication, documentation, and organizational skills.
• Ability to manage multiple priorities and work independently in a dynamic environment.

Continuing Education Requirements

Personnel are expected to maintain required licensure and participate in continuing education as required by regulation and organizational policy.

Environmental & Working Conditions

May be exposed to extremes of heat and cold, infectious diseases, emergency situations, and blood or bodily fluids.
OSHA Exposure Category: I

This organization does not discriminate in hiring or employment on the basis of ancestry, race, color, religion, national origin, sex, sexual orientation, age, military status, veteran status, or disability. No question on the application is intended to secure information to be used for such discrimination. This application will be given every consideration, however its receipt does not imply employment for the applicant.