Nurse Navigator, Hospital at Home

Position Overview

The Hospital at Home Nurse Navigator is responsible for providing high-quality discharge planning, care coordination, and follow-up care within UChicago Medicine’s Acute Hospital Care at Home model. In this role, the nurse navigator acts as a patient advocate by using critical thinking skills to coordinate timely care and educate patients and caregivers regarding their individualized care plans, technologies, and protocols—all while ensuring adherence to National Patient Safety Goals.

Key Responsibilities

• Maintains the ability to manage a designated caseload and adapt to rapidly changing priorities.
• Collaborates with multidisciplinary teams to ensure smooth transitions to home care and safe discharge processes.
• Plans and facilitates clinical health coaching strategies to support patient self-management of acute and chronic conditions.
• Identifies patients in need of community support and addresses social determinants of health to remove barriers to care.
• Communicates all critical elements of the care and transition plans to physicians, team members, patients, and their families.
• Guides patients and families through the continuum of care within the Hospital at Home phases.
• Monitors and escalates biometric data in accordance with UChicago Medicine protocols.
• Conducts audio/visual patient care visits as directed by the care team or established protocol.
• Ensures efficient, patient-centered implementation of all interventions outlined in the care plan.
• Leverages resources and partner expertise to implement collaborative workflows, standards, and evidence-based clinical protocols.
• Adheres to clinical protocols and pursues necessary training to deliver evidence-based care.
• Promotes a culture of safety and professional practice through active engagement in process improvement.
• Completes tasks related to transition of care outreach, documentation, and follow-up care.
• Provides protocol-driven assessments, coordinated care, and interventions tailored to diverse patient populations.
• Exhibits sound clinical decision-making and critical thinking skills while adhering to nursing guidelines and state/hospital regulations.
• Facilitates admissions to the Hospital at Home program in line with established guidelines.
• Identifies, prevents, and addresses complex or recurring patient care issues by applying nursing expertise.
• Shares clinical expertise with the multidisciplinary team and serves as a resource in specialized areas.
• Supports research initiatives that advance evidence-based practice.
• Maintains an ongoing caseload for regular outreach and management of patients.
• Educates patients and caregivers on the care plan, technologies, and processes associated with acute care at home.
• Adopts new technologies and clearly communicates their use to patients.

Required Qualifications

• Education: Associate degree required.
• Experience Required: 5 years of Registered Nurse experience in an acute care setting.
• Qualifications: Must be able to communicate effectively in English; demonstration of core competencies within 90 days; completion of all position-specific competencies within 12 months; current RN Illinois license; current BLS certification upon hire or within 30 days.

Benefits & Perks

• Compensation: Pay range is based on full-time equivalent market data and will vary based on candidate qualifications and internal equity.
• Benefits: Comprehensive benefits package is available—please review the full complement of benefit options at UChicago Medicine’s Benefits page.