Lead, Nurse Navigator and Care Transitions Population Health

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The Lead for Nurse Navigation, Nurse Triage, and Care Transitions will assist with strategic and operational oversight for programs that ensure safe, effective, and patient-centered transitions across care settings and timely clinical triage support, ensuring high-quality care coordination. This role helps to ensure adherence to protocols, quality standards, and performance metrics. Develops and monitors practices and procedures for the staff as well as provides training and orientation to all new and current team members. The Lead collaborates with leadership, clinical teams, community resources, and internal stakeholders to optimize continuity of care, reduce readmissions, and improve patient outcomes.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC) OR must hold current WV Registered Nurse AND must obtain additional Registered Nurse License in ALL of the following states within 6 months of hire: • Maryland • Pennsylvania • Ohio • Kentucky • Virginia • West Virginia.

2. Associate’s degree in nursing and 7 years of clinical experience in a healthcare setting.

OR

3. Bachelor of Science in Nursing (BSN) and 5 years of clinical experience in a healthcare setting.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor of Science in Nursing (BSN).

EXPERIENCE:

1. Ambulatory and/or care coordination experience.

2. One (1) year of supervisory experience is strongly.

Core Duties and Responsibilities: The statements described here are intended to describe the general nature of work being performed by people assigned to the position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Direct daily operations review of the transition and triage services, daily volumes, and assigned duties.

2. Ensure compliance with established workflows, documentation standards, and regulatory requirements.

3. Monitor performance, including outreach timeliness, triage response times, patient engagement, and quality outcomes.

4. Work with leadership to develop and implement process improvements to enhance efficiency and patient experience.

5. Routine daily interaction with staff to assist with essential functions and provide guidance as needed and acts as a subject matter expert to help optimize the team’s performance and function.

6. Mentor and coach Nurse Navigators and care transition roles within the population health team to develop team members.

7. Provide training and ongoing education on clinical protocols, EMR documentation, and patient engagement strategies.

8. Provide onboarding and training of new hires and collaborate with mentors to support orientation needs and experiences.

9. Foster a collaborative, team-oriented environment that supports innovation and continuous improvement.

10. Assist in hiring new staff.

11. Work with management  to address performance improvement areas through structured plans, interventions, and follow-up.

12. Review and support staffing needs for daily operations.

13. Oversee identification and outreach to patients discharged from inpatient, skilled nursing, rehabilitation, and emergency department settings.

14. Maintain and stay current with knowledge base of transition guidelines and requirements.

15. Ensure medication reconciliation, follow-up appointment scheduling, and barrier resolution are completed as outlined, ensuring documentation to support outcomes.

16. Review and evaluation of triage workflows and use of protocols to ensure timely and accurate assessment of patient needs and appropriate disposition.

17. Report escalation of concerns to leadership for appropriate coordination of interventions.

18. Promote integration of social determinants of health and review of predictive risk score and chronic diseases into evaluation of patient for resource referrals.

19. Utilize EMR reports and data analytics to track performance and identify trends.

20. Prepare and present performance audits to leadership with any outlined areas for improvement and collaborate to develop any educational needs or workflow adjustments.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Must be able to sit or stand for extended periods of time.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment and remote work set up.

2. Some rotational availability for urgent issues outside standard business hours as needed to support 24/7 staffing.

SKILLS AND ABILITIES:

1. Strong leadership and team-building skills.

2. Excellent communication and interpersonal abilities.

3. Proficiency in EMR systems (Epic preferred) and data-driven decision-making.

4. Ability to manage multiple priorities in a fast-paced environment.

5. Preferred knowledge of transitions of care best practices, nurse triage protocols, and population health principles.

6. Proficiency in Microsoft Office

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

SYSTEM West Virginia University Health System

Cost Center:

415 SYSTEM Population Health Management