Nurse Navigator - Community Care Center
Company: Hartford Hospital
Location: Middletown
Posted on: July 1, 2025
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Job Description:
Location Detail: 132 Jefferson St Hartford (10483) Shift Detail:
Monday through Friday, 8a - 430p Work where every moment matters.
Every day, more than 40,000 Hartford HealthCare colleagues come to
work with one thing in common: Pride in what we do, knowing every
moment matters here. We invite you to become part of Connecticut’s
most comprehensive healthcare network. Hartford Hospital is one of
the largest and most respected teaching hospitals New England. We
are a Level 1 Trauma Center that provides cutting edge treatment to
its patients. This is made possible by being home to the largest
robotic surgery center in the Northeast and the Center for
Education, Simulation and Innovation (CESI), one of the
most-advanced medical simulation training centers in the world.
When hospitals cannot provide the advanced care, expertise and new
treatment options their patients require, they turn to us. The
Community Care Clinic (CCC) is located at 132 Jefferson St on the
third floor of the Hartford Hospital Community Health building of
Hartford Hospital. CCC clinic has close to 3,000 patient visits
annually with an average of 50 patients per day. The Division of
Infectious Diseases provides inpatient and outpatient consultation
regarding the diagnosis and management of all types of infectious
diseases. The service is supported by outstanding clinical
diagnostics laboratories, which provide state-of-the-art techniques
for rapid diagnosis of infectious diseases. Our staff of providers,
Psychiatry, fellows, Psych Residents, social worker, Nutritionist,
Pharmacy Liaison, APRNs, RNs, MA/MAAs, a Case Manager and a Data
Manager who provides compassionate care, excellence in teaching and
investigations in clinical and laboratory research. CCC is Ryan
White funded. 75% are bilingual with Spanish being their primary
language. 80% of our patients have Health coverage under Medicaid.
Our specialists are skilled at treating many infectious conditions,
including: Conditions such as HIV infection, Hepatitis, fever of
unknown origin, recurrent infections or rashes of unknown type or
origin, Influenza, Opportunistic infections in patients who are
immunosuppressed due to acquired or congenital immunodeficiency,
transplant or other medical condition. CCC guides patients through
the health system, including appropriate referrals for services to
other health professionals. Job Summary: Functioning within the
context of the framework for professional nursing practice, the
Community Care Nurse Navigator is a registered nurse experienced in
patient throughput, preventing transitional care gaps, and
resolving issues to enhance the quality and continuity of a
patient’s or populations health care leading to improved health
outcomes and equitable care. This role supports the HHC mission to
improve the health and healing of the people and communities we
serve. Under provider direction, the Community Care Nurse Navigator
provides skilled nursing care to patients in a variety of clinical
settings. Scope of responsibility is characterized by use of
nursing process to assess, plan, intervene and evaluate human
responses to actual or potential health problems utilizing
appropriate practices, standards, protocols and guidelines. This
position reports to a Practice Manager. Job Responsibilities: •
Functions as a member of an interprofessional care team in an
expanded nurse role to help patients transition from the acute care
setting (HH ED or inpatient). The goals include reducing all-cause
readmissions, and inappropriate ED utilization, improving care
coordination for patients during the transitional care period, and
ultimately improving care quality and access for vulnerable
populations. This role will be responsible for educating the HH
community at large and advocating for resources to enhance patient
healthcare engagement and expand the collaboration and
communication between
(inpatient/ambulatory/outpatient/attending/transitional
care/specialty care/primary care) providers and care teams for high
risk/complex patients. • Partners with the inpatient (i.e. acute
care, IOL, STR) or ED physician and care team to proactively
identify potential transitional care gaps for this patient
population, and establish a safe transition plan. Key strategies
include ensuring a patient/caregiver agreed upon CCC Clinic and
urgent specialists scheduled appointment(s) with transportation,
verifying patient has necessary DME, finalizing an achievable
community medication plan, completing diagnostic workup, educating
the patient on disease and symptom management, and incorporating a
patient-centered home care plan. • Performs post-hospitalization/ED
transitional care strategies within 24-48h after discharge,
including post-discharge phone calls, patient education, symptom
management, and medication reconciliation, and collaborates with
CCC clinic physician and (clinic and community) care team to
minimize identified gaps in care. • Throughout the
post-inpatient/ED transitional care period, facilitates the
completion of the diagnostic workup, follows up on unresulted
diagnostics, collaborates with homecare, pharmacy, and DME to
ensure the patient has necessary supplies/medications/resources,
obtains necessary authorizations, and schedules additional
consultant appointments. • Collaborates with clinic physicians to
resolve issues and to advance the treatment plan until the patient
has an established primary care provider. • In collaboration with
the CCC Clinic physician, assists the patient in identifying a
primary care practice for continued care and facilitates the
transfer of care to that practice • Documents all communication,
transition plan, implemented strategies, and patient outcomes in
EPIC. • As a member of the CCC Clinic completes transitional care
strategies and actions per CMS/Payer guidelines for Transitional
Care Management or other program directives. • Establishes a
therapeutic rapport with patients and demonstrates a commitment to
serve as a patient advocate. • Demonstrates the ability to work
independently as well as collaboratively as a member of the health
care team in order to provide safe patient care and prompt and
efficient service. The Community Care Nurse Navigator provides
transitional care strategies to his/her peers/colleagues and
patients based on need/coverage. • Attends/Leads and actively
participates in care team meetings to facilitate a safe transition
plan or resolve a patient issue. • Establishes evidence-based
standard work and workflows. Develops and implements processes that
improve the patient experience. Collects and analyzes patient and
program level data identifies areas of opportunity, recommends
improvements/revisions or program development, and
leads/participates in the idea/plan implementation. • Applies the
nursing process as appropriate within the context of the
organization’s framework for professional nursing practice and
following guidelines established by the team. • Provides
office-based nursing care in collaboration with provider,
communicates with provider regarding patient needs, nursing
assessments, and recommendations, demonstrates independent nursing
actions based on assessment and problem identification. This is a
grant funded position. Qualifications Bachelor’s Degree required,
MSN preferred • Minimum five (5) years of nursing experience,
Inpatient and Ambulatory nursing experience preferred. • Current
Connecticut Nursing License • BLS Certification • Obtain CCM/CCCTM
certification within two years of hire We take great care of
careers. With locations around the state, Hartford HealthCare
offers exciting opportunities for career development and growth.
Here, you are part of an organization on the cutting edge – helping
to bring new technologies, breakthrough treatments and community
education to countless men, women and children. We know that a
thriving organization starts with thriving employees we provide a
competitive benefits program designed to ensure work/life balance.
Every moment matters. And this is your moment. As an Equal
Opportunity Employer/Affirmative Action employer, the organization
will not discriminate in its employment practices due to an
applicant’s race, color, religion, sex, sexual orientation, gender
identity, national origin, and veteran or disability status.
Keywords: Hartford Hospital, Middletown , Nurse Navigator - Community Care Center, Healthcare , Middletown, Connecticut
