Patient Care Navigator

JOB DESCRIPTION

As a Patient Care Navigator, you will be responsible for organizing and coordinating patient care activities to ensure optimal patient outcomes. This involves collaborating with healthcare providers, patients and families to facilitate communication, address concerns, and resolve issues. By acting as a liaison between patients, their families, and the healthcare team, you will contribute to a seamless and positive patient experience.

You will also be expected to understand, support, and promote SEHA’s mission, vision, and values. Provide age-appropriate patient care aligned with the Nursing Scope of Practice as defined by the Department of Health. This includes demonstrating professional leadership by supervising the patient care team and upholding clinical standards and quality of patient care within their specialty. Furthermore, nurses are obligated to adhere to and promote the Professional Nurses Code of Conduct while actively promoting health and delivering health education

RESPONSIBILITIES

Key Responsibilities of the roleCorresponding Key Activities performed by the role

Managerial/ Technical

• Provides professional leadership, acts as a role model, and mentors fellow nursing staff.
• Demonstrates critical thinking and provides leadership in conflict management and problem-solving.
• Promotes and supports a collaborative practice model.
• Monitors staff performance, providing regular constructive feedback, coaching, guidance, and support to team members.
• Acts as a preceptor to less experienced staff and participates in organizational change initiatives.
• Monitors and coordinates effective and efficient utilization of human resources, consumables, and equipment.
• Monitors clinical care to ensure clinical standards are met, identifies variances, and initiates corrective measures as required.
• Participates in staff performance evaluations and achievement of annual performance goals.
• Participates in unit budget preparation and monitors resource usage.
• Adopts an interdisciplinary team approach based on mutual respect and direct communication between health professionals.
• Establishes rapport with patients and families, communicates effectively, and addresses their concerns and needs.
• Liaises with the Nurse Manager/Nurse Supervisor to ensure appropriate staffing and skill mix, and serves as a liaison between patients, families, caregivers, and the healthcare team.
• Educates healthcare professionals and employees on patient experience.
• Adheres to and promotes the Professional Nurses Code of Conduct.
• Responds to and investigates complaints and concerns and communicates identified issues to appropriate staff and department.
• Works with individuals or departments to address issues related to care delivery.
• Educates health care professionals and employees on the varied ways to humanize a patient’s experience based on feedback from individual patients and their families.
• Interacts with patients, families, customers and utilizes feedback to improve and reinforce satisfaction.
• Assesses patient or family questions and concerns and develops a plan to address needs.
• Communicates information to appropriate person(s) in appropriate time frames to meet patient or family questions, concerns, and expectations.
• Initiates patient or family concern reports, as appropriate, when issues arise.
• Consults, collaborates, and cooperates with colleagues, peers, supervisors, and other health care providers in a professional manner to improve the quality, effectiveness, and efficiency of patient care
  

Quality & Safety

• Anticipates patient family needs, understands their expectations and responds appropriately.
• Treats others with compassion, fairness, courtesy and respect while honoring their uniqueness.
• Willingly works with others to identify and achieve common goals.
• Enthusiastically approaches their role and displays pride in the organization.
• Takes personal responsibility for doing the right thing.
• Must demonstrate exceptional communication skills along with excellent customer service skills.
• Must be able to perform a variety of duties, often changing from one task to another of a different nature, without loss of efficiency or composure, and be able to perform under stressful conditions when confronted with multiple requests, demonstrating prioritizing skills.
  

Education

• Planning, teaching, supervising and counseling (as required) regarding physical care measures to promote improvement/recover, symptom/complication management, expected disease progression, social/emotional care and community resources
• Facilitating patient family based on identified learning needs of the patient and/or those providing care and documents appropriately
• Assess patient and family education needs, plan for and provide education and evaluate outcome
• Provides a suitable environment that supports patient and family learning.
• Acts as a resource nurse to ensure patient and family are provided with accurate
• information and resources to meet their health care needs.
• Engages in health promotion activities in the organization and community.
  

Facility specific Responsibilities of the roleCorresponding Activities performed by the role

Direct Patient Care

• Assess patient needs, identify barriers, and develop individualized care plans.
• Serve as a primary contact and advocate for patients, build trust, and provide emotional support.
• Navigate the healthcare system, locate resources, and coordinate services to ensure timely access to care.
• Make follow-up calls to discharged patients, monitor patient progress, and address concerns.
• Provide education on treatment side effects, self-management strategies, and refer patients to support groups and integrative therapies.
• Collaborate with physicians, nurses, social workers, and other healthcare providers to ensure coordinated care.
• Maintain accurate and complete documentation and facilitate effective communication within the healthcare team.
• Coordinate referrals to specialists, community services, and other healthcare providers.
• Monitor patient outcomes and identify opportunities for improvement.
• Promote and utilize evidence-based practices to enhance patient care.
• Adhere to regulatory standards, organizational policies, and procedures to ensure patient safety.
• Facilitate a climate of mutual understanding and appreciation of cultural differences.
• Administer medications according to organizational policies and procedures.
• Respond to emergencies according to organizational protocols.
• Provide guidance and advice to nursing staff on clinical and administrative matters.
• Facilitate a collaborative approach with other health professionals to ensure appropriate continuous, coordinated and integrated patient care.
• Anticipates patient family needs, understands their expectations and responds appropriately.
  

Communication

• Daily interaction with Lead Clinicians & Clinical Nurse Specialists
  • Medical Secretaries
  • Multidisciplinary Team members (MDTs)
  • General manager within specific directorates
  • Lead Cancer Nurse / Manager Cancer for Cancer Performance
  • Service Managers within specific directorates
  • Service Improvement Facilitator
  • MDT Coordinators
  • Pathology and Imaging departments
  • Out-patient central appointments
  • Case Management team memebers
  • MDT Coordinators / MDT members at referring other SEHA or Patients / relatives / carers
  • Other physicians in SEHA or other hospitals in the country.
• Communicate with all levels of staff at SEHA HCF and other hospitals within and outside SEHA network, general physicians and patients to obtain or verify relevant information relating to cancer waiting times and to share best practice.
• Understand and communicate to clinical teams annual Cancer Waiting Times targets and be aware of the performance impact on, if targets are not met.
• Respond to patient queries about pending investigations, surgical in-patient dates, outpatient dates
• Makes follow-up phone calls to discharged patients, particularly those at moderate to high risk of readmission according to the inpatient readmission risk assessment score (LACE). The phone call must address how patients are adjusting at home, ensure compliance with medication, address any pain management issues, confirm follow-up appointments, and address any care-related concerns with relevant stakeholders. Additionally, solicit feedback about their hospital experience, and forward any clinical questions to the appropriate provider.
• Maintains confidentiality and security of patient, family, and organization information in
• accordance with the confidentiality policy
• Facilitates effective communication between the patient, family and the interdisciplinary
• health care team as required.
• Liaise with other health care providers as necessary to ensure appropriate and timely
• interventions for patients and for discharge planning.
• Provides a comprehensive clinical handover / report as required to ensure patient safety.
• Attends Patient Care rounds and communicates and updates the attending Healthcare
• provider on changes in the patient’s condition.
• Communicates with patient care team ongoing changes in patient’s plan of care and unit
• activity
• Ensures the nurses communicate and report changes in the patient’s condition to the
• relevant health care provider and that new orders are carried out
• Ensures documentation reflects a continuous, systematic and accurate nursing process
• Ensures clear and accurate documentation of all patient care events and is compliant with
• organization policies and procedures.
• Monitors and audits compliance with organization documentation standards
• Establishes and maintains professional boundaries with patients and members of the
• healthcare team.

Outpatient Pathway

• Ensure that any diagnostics and investigations that are required as part of the patient pathway have been requested and that the results are available for consultations. This will include those that are carried out at other SEHA/private facilities.
• Coordinate appointments and procedures at other hospitals and organizations, where the pathway requires input from these.
• Ensure that SEHA/ agreed standard of service is delivered to patients requiring elective admission to specialty
• Use EMR systems and specialty databases to ensure relevant and accurate information is recorded.
• Provide cross cover within specialty
• Attend meetings for service development initiatives as required
• To be responsible for the organisation of formal patient related meetings. Responsibilities to include preparation of agendas, transcription of minutes and subsequent collation and distribution to staff
• To be able to contribute to specialty improvements and efficient processes
• Demonstrate high levels of customer care and be an ambassador for customer care within the SEHA.
• To be the friendly, sensitive and accessible focus for patient and carer communication, ensuring that all patients have the opportunity to agree their appointment and admission dates
• Act as the communication hub for clinical team, other sub-specialties, patients and their relatives, as well as internal and external organizations (provide permission granted from higher administration).
• Promptly answer telephone enquiries, taking and relaying messages in polite, and helpful manner, taking action as appropriate
• Deal with complex queries
• Ensure interpreting service is available when required for patient consultations
• To be responsible for timely written and verbal communications with patients, clinicians, nursing staff and management
• Ensure that all information distributed to patients is accurate and up-to-date
• Attend clinics where appropriate to coordinate the patient pathway
• Identify own training and development needs and undertake appropriate training/education as required.
• Participate in an annual individual performance review process where objectives will be agreed, performance monitored and personal development needs discussed
• To attend all mandatory training as and when required to do so.
  

Program Development

• Participate in the execution of quality assurance programs and projects.
• Collaborate in the development of protocols and guidelines for patient management
• Develop, implement and evaluate comprehensive patient education programs
• Ensure health care professionals comprehensive knowledge of processes and procedures of care coordination specialty.
• Participates and/or leads quality improvement activities by assisting with the development,
• implementation and review of standards, policies, procedures and guidelines, evaluation of
• indicators and reporting of outcomes and trends.
• Monitors and evaluates unit operation and services in order to identify problems and takes
• a lead role in improving systems and safe patient care
• Participates in interdisciplinary teams and Performance Improvement Projects for
• evaluation and improvement of processes and clinical practice
• Ensures provision of a clean and safe working environment that minimizes risks to
• patients, visitors, other staff, and self. Identifies faulty and defective equipment and
• furniture, removes from service and takes corrective action
• Complies with International and HAAD Patient Safety Goals
• Promotes and audits compliance with the organization’s Infection Control policies and
• procedures
• Identifies, investigates, reports, and implements corrective action for incidents or
• complaints as appropriate. Completes appropriate documentation according to
• organization policy.
• Delegates responsibilities to the nursing team in response to an emergency situation.
• Identifies learning needs of the junior staff on the Unit in conjunction with the Clinical
• Resource Nurse and Manager and assists with the implementation of educational
• activities.
• Is responsible for educating less experienced staff in adverse drug reaction and the
• process to be followed for medication errors
• Completes mandatory and unit specific competencies and demonstrates ongoing competence
• In conjunction with, but not limited to, the Line Manager/CRN, identifies own professional
• learning needs and develops an annual learning plan
• Develops and maintains own Professional Portfolio as per HA-AD policy.
• Demonstrates improvement in clinical practice as a result of application of new theoretical
• knowledge and technology
• Initiates or participates in Nursing and or other disciplines research that contributes to
• continual improvement in standards of care
• Obtains accredited and non-accredited Continuing Nursing Education (CNE) Units in
• compliance with HAAD and the organization’s requirements
• Demonstrates evidence of ongoing professional development in leadership and management
  

General

• This job description is not definitive and following periodic review may be subject to
• change.
• The charge nurse will also be expected to contribute to the wider corporate and
• organisational development needs as appropriate within scope of practice.
• The charge nurse will be expected to ensure compliance with the requirement of the
• Health and Safety regulations of the hospital
• Upholds the organization customer service standards at all times
  

Qualifications

QUALIFICATIONS

Required:

Bachelor degree in nursing or equivalent qualification of NLT 3 years study duration from an

accredited program;

• AND Valid/current national license.
• AND BLS
  

Desired:

ACLS, PALS

Specialist Certifications

Required: N.A.

Desired:

• Care Coordination certfication
• Area of spcialty certifciation.
  

Experience Required in addition to the Qualifications mentioned above (Relevant to the Job)

Required Experience

• Charge Nurse experience + 2 years experience as per DOH PQR
• Staff Nurse experience as per DOH PQR / + 4 years experience
• Being current SEHA Charge Nurse or Staff Nurse with no experience in Care Coordination but Completed SEHA specialty Training Program in lieu of Experience required (this condition is applicable only for current SEHA employees not new joiners)
  

OR

OR

Desired:

Experience in tertiary Healthcare facility

Required:

Additional Requirements / Remarks

Excellent Communication skills

Desired:

Arabic Language

Physical Requirements

The position requires a considerable amount of physical work at least 25% of the time. In addition, the position requires office work involving extensive use of the computer and interdepartmental coordination.

The individual must be able to quickly maneuver throughout halls, stairways and patient rooms in response to hospital emergencies.

The position requires a considerable amount of physical work at least 25% of the time. In addition, the position requires office work involving

extensive use of the computer and interdepartmental coordination.

The individual must be able to quickly manoeuvre throughout halls, stairways and patient rooms in response to hospital emergencies.

The following denote the key physical requirements for the job which may require:

• Standing
• Walking
• Sitting
• Stairs
• Simple Grasping
• Fine Manipulation
• Operation Machinery / Equipment
• Lifting / overhead reaching
• Twisting
• Climbing / Balancing
• Crouching / Squatting
• Manual handling of people
• Reaching