Job Description

Clinical Services Navigator RN

Job Code: CM6000

ABOUT US

We are welcoming a new era in healthcare where achieving good health is just the beginning. At UVA Health Northern VA & Culpeper, we believe in caring for the whole person by getting to know – and making connections with – our patients. By combining the talent and expertise of our people, the breadth of capabilities across our system, and our commitment to helping our communities get better and stay healthy, we are improving the patient experience.

As a UVA Health Northern VA & Culpeper team member, you will have a voice in patient care decisions, support the most advanced medical technologies and feel a strong sense of satisfaction from making a difference in people’s lives every day.

JOB TYPE

Classification: Exempt

Supervises Positions:

The Clinical Services Navigator will facilitate care coordination from acute to ambulatory and is a valued member of the healthcare team. They collaborate with Physicians, Case Managers, and other members of the healthcare team to facilitate coordination of care and follow-up appointments to the ambulatory setting. Collaborates with Case Managers for guidance with medically and/or psychosocially complex cases. Serves as a resource for care coordination. Maintains current knowledge of available community resources, post-acute care and ambulatory options.

QUALIFICATIONS

Education: 4 Year/Bachelor's Degree preferred.

Experience: 2 years of experience preferred. 5 years of clinical experience with knowledge in the care of disease specific population preferred. Refer to the Life Support Training Policy for additional details.

Licensure: RN required. Certified in specialized area preferred. National specialty certification required, or obtained within 2 years, if applicable to position.

Additional Skills/Requirements Required: Demonstrates effective communication skills to provide patient education. Demonstrates effective communication skills to discuss case management, financial, clinical issues with hospital-based case managers, physicians, outside agencies and facilities, nurses, and other healthcare professionals in the community. Autonomous, self-starter with the ability to make independent decisions. Organized with effective time management skills. Detail oriented with ability to facilitate change and affect positive results. Proficient in computer/web-based tools.

Additional Skills/Requirements Preferred: N/A

Competencies

• Patient Care & Education: 
  • Provides patient and family education regarding the surgical pathway, ERAS protocols, recovery expectations, and discharge planning.
  • Reinforces health promotion, mobility, and illness prevention strategies in collaboration with the care team.
  • Reviews patient records to identify needs, barriers, and opportunities for support across the care continuum.
  • Recommends and connects patients/families to appropriate community resources and support services.
  • Provides ongoing patient phone contact pre- and post-operatively to ensure understanding, readiness, and continuity of care.
• Quality & Safety:
  • Collaborates with interdisciplinary teams to achieve desired quality outcomes (e.g., reduced LOS, readmission prevention, infection reduction, and same-day discharge targets).
  • Monitors patient outcomes and pathway adherence to identify trends and opportunities for improvement.
  • Applies principles of safety and infection prevention in all patient interactions.
  • Participates in quality initiatives, audits, and process improvement activities to support departmental and organizational goals
• Communication & Collaboration
  • Demonstrates strong interpersonal and communication skills in interactions with patients, families, and colleagues.
  • Functions as a central point of contact for patients, ensuring consistent messaging across the care team.
  • Collaborates effectively with physicians, nursing, PT/OT, anesthesia, and case management to coordinate care and discharge planning.
  • Participates in interdisciplinary rounds, staff meetings, and care conferences to support shared goals.
  • Identifies opportunities for process improvement and communicates feedback from staff and patients to leadership.
• Clinical Knowledge & Care Coordination
  • Demonstrates knowledge of orthopedic care pathways, including ERAS protocols, pain management principles, and discharge criteria.
  • Assesses patient readiness for surgery and recovery by reviewing records, identifying barriers, and escalating concerns appropriately to providers or case management.
  • Tracks and documents patient progress across the continuum to ensure alignment with clinical pathways and program metrics.
  • Supports transitions of care by scheduling follow-up appointments, coordinating services, and ensuring patients understand next steps in their care journey.
  • Maintains up-to-date knowledge of hospital services, community resources, post-acute care, and ambulatory options to support patient needs.

The incumbent may be asked to perform additional duties as assigned.

PHYSICAL DEMANDS

Physical Demand Code: Medium to Heavy Physical Demand: The job requires constant standing, frequently walking, and bending/stooping. Proficient communicative, auditory, and visual skills. Attention to detail and ability to write legibly. Ability to lift/push/pull 100 lbs. For any weight over 35 lbs., use Safe Handling Equipment. This job description may not include all assigned duties, responsibilities, or aspects of the job described. It may be amended at any time at the sole discretion of UVA Community Health.

OTHER

• May require the use of safety equipment, such as HEPA mask, for infection prevention:
• On call responsibilities as directed:
• Ability to travel between campus buildings, remote facilities, and out of town as needed:

• Yes
• Yes
• Yes