Job Description

Job Description

Job Description

We enrich the lives of those we serve by providing a nurturing environment that fosters joy, purpose, and well-being. The Sharon at SouthPark is a continuing care retirement community for senior residents located near the heart of SouthPark. We are a non-profit long-term care facility that offers independent living, assisted living, and skilled nursing care. At the Sharon at SouthPark our team member's number one responsibility is to deliver compassionate resident care every time! We believe by demonstrating our unifying principles of stewardship, unity, purpose, excellence in service, respect, and beauty this can be achieved daily.

SUMMARY

The Nurse Navigator (RN) serves to support the organization’s commitment to a seamless continuum of care by enhancing resident outcomes, promoting independence, and strengthening care transitions. As the clinical liaison and care coordinator for Independent Living residents, the Nurse Navigator guides the residents through the full continuum of care within the community.

The Nurse Navigator enhances outcomes, improves communication, and supports a person-centered approach to wellness. This role proactively supports residents in maintaining independence, navigating healthcare decisions, coordinating transitions (Independent Living to Assisted Living, Skilled Nursing, Home Care, or external providers), and ensuring seamless communication across care settings. The Nurse Navigator works in partnership with the Director of Nursing and collaborates with Skilled Nursing leadership and coordinates with Social Services Coordinates with Social Services.

ESSENTIAL DUTIES AND RESPONSIBLITIES include the following (other duties may be assigned):

Care Coordination & Navigation

• Serve as the primary clinical point of contact for residents and families to help them navigate the healthcare system.
• Assess resident needs and develop individualized care plans focused on wellness, safety, and optimal outcomes.
• Coordinate and manage transitions across all levels of care, including hospital discharge planning, short-term rehabilitation, return to Independent Living, and potential movement to Assisted Living or Skilled Nursing. This is done while ensuring continuity, accuracy, and timely communication
• Collaborate with physicians, therapists, nursing staff, social workers, and wellness professionals to support comprehensive, integrated care.
• Facilitate scheduling of appointments, follow-ups, diagnostic testing, and specialist referrals.

Resident & Family Support

• Provide education on diagnoses, medications, treatment plans, and healthy lifestyle behaviors.
• Coach residents and families to improve health literacy and confidence in managing conditions.
• Offer anticipatory guidance, emotional support, and resources to help residents make informed decisions.

Examples in this area include post-hospital discharge, new chronic diagnosis, high-risk residents, frequent ED utilizers, and cognitive decline concerns

Clinical Oversight

• Conduct clinical assessments for new admissions, return-from-hospital evaluations, and ongoing wellness check-ins as appropriate.
• Monitor high risk residents for changes in condition and intervene or escalate concerns promptly.
• Review medical records, lab results, and provider recommendations to ensure clarity and accuracy.
• The Nurse Navigator does not provide ongoing skilled nursing services unless ordered under an approved home care plan but facilitates coordination and communication of clinical services.

Interdisciplinary Collaboration

• Participate in care plan meetings, case reviews, and wellness team huddles.
• Promote a holistic, person-centered approach by integrating physical, emotional, social, and cognitive wellness.
• Serve as a liaison between residents, families, healthcare partners, and community resources.

Quality, Compliance & Documentation

• Maintain detailed and accurate documentation within the electronic medical record (EMR).
• Escalates urgent clinical concerns according to established clinical protocols and emergency response procedures.
• Track outcomes, identify patterns, and support quality improvement initiatives.
• Uphold all regulatory requirements, infection control standards, and nursing best practices: Reduce avoidable hospital readmissions
• Improve resident satisfaction with healthcare navigation.
• Increase timely post-hospital follow-up compliance.
• Support appropriate level-of-care placement decisions.

Qualifications

Education & Licensure

• Current Registered Nurse (RN) license in the state of practice, in good standing.
• Bachelor of Science in Nursing (BSN) preferred.

Experience

• Minimum 2–3 years clinical nursing experience (geriatrics, care management, acute care, or home health strongly preferred).
• Experience with care coordination, case management, or patient navigation is highly desirable.

Skills & Competencies

• Strong communication, relationship building, and teaching skills.
• Ability to navigate complex clinical situations with empathy, clarity, and professionalism.
• Excellent critical thinking, prioritization, and problem-solving abilities.
• Comfort working both independently and collaboratively within an interdisciplinary team.
• Proficiency with electronic medical records and documentation standards.

Core Behaviors & Values

• Person-centered, resident first mindset.
• Commitment to wellness, dignity, and holistic care.
• Compassion, patience, and strong ethical practice.
• Drive for continuous improvement and exceptional service.

This role supports the organization’s commitment to a seamless continuum of care by enhancing resident outcomes, promoting independence, and strengthening care transitions.

PHYSICAL DEMANDS:

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. While performing the duties of this job, the employee is regularly required to stand, walk, sit, use hands to finger, handle or feel; reach with hands and arms; talk or hear; and taste or smell.

The employee is occasionally required to lift, climb, or balance and stoop, kneel, crouch or crawl. Specific vision abilities required on this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus. May work on a computer; up to 8 hours in a day. May work on a computer; up to 8 hours in a day. Work is performed in clinical, residential, and office environments.

The employee must frequently lift up to 30 pounds unassisted and push and/or pull medication carts unassisted in excess of 25-35 pounds.

ACCESS TO PROTECTED HEALTH INFORMATION:

The employee shall have limited access to demographic and personal information: Name, Address, city, state, zip code, telephone number, insurance carrier, social security number, date of birth and medical record number.

The above statements are intended to describe the general nature and level of work being performed by people assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required of personnel so classified.

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Subject to moderate physical, an emotional stress associated with Nurse Navigator RN role. While performing duties of this job, the employee will be exposed to inside and outside environmental conditions. While performing duties of this job, the employee will have potential exposure to cleaning chemicals, biohazardous materials, blood/blood borne pathogens, other bodily fluids and residents with communicable diseases.

OTHER DUTIES:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

The Sharon at SouthPark is an Equal Employment Opportunity (EEO) employer.

Taking care of our residents begins with taking care of our Employees.

Company's website: thesharon.org

Per company policy Proof of Influenza vaccine and/or approved medical/religious exemption is required for all employees.

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