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Nurse Navigator

SPECTRUM HEALTHCARE SOLUTIONS PLLC
Oklahoma City, OK

Quick Apply

Job Details

Full-time

Qualifications

Collaborate with healthcare professionals
Nursing home experience
Care documentation
Long-term care facility experience
Managing patients as a nurse case manager
Transitional care planning in clinical case management
Patient transport coordination
Multidisciplinary team collaboration for treatment planning
LPN
Cross-functional communication

Full Job Description

Care Coordinator / Nurse Navigator (LPN)

Post-Acute & Hospital Transitions Specialist

Position Summary

The Care Coordinator / Nurse Navigator (LPN) supports safe, efficient transitions between skilled nursing facilities (SNFs), nursing homes, and hospitals by coordinating care plans, improving communication between providers, and reducing avoidable readmissions. This role serves as a clinical liaison across care settings and helps ensure continuity, compliance, and patient-centered outcomes during transitions of care.

This position requires an experienced LPN with direct SNF/nursing home background and strong working knowledge of post-acute workflows, discharge planning, and regulatory expectations.

Key Responsibilities

Transition-of-Care Coordination

Coordinate patient transfers between SNFs, hospitals, and post-acute providers
Perform admission and readmission transition reviews
Ensure completion and accuracy of transfer documentation
Support safe discharge planning from hospital to facility
Assist with high-risk patient tracking and follow-up

Clinical Communication & Liaison Support

Serve as liaison between:
- facility nursing teams
- hospital case management
- attending providers
- medical directors
- therapy teams
Communicate changes in condition to appropriate stakeholders
Support implementation of provider care plans across settings

Readmission Prevention

Identify patients at high risk for hospitalization
Monitor early warning indicators:
- falls
- infections
- medication changes
- decline in functional status
- abnormal vitals/labs
Coordinate early intervention strategies with providers and facility teams

Documentation & Compliance

Review transfer packets for completeness and accuracy
Ensure continuity of:
- medication reconciliation
- code status
- advance directives
- diagnoses and problem lists
Support regulatory compliance with CMS transition-of-care expectations

Facility Collaboration

Participate in:
- IDT meetings
- QAPI initiatives
- readmission review processes
Assist facilities in improving transition workflows
Support communication with corporate clinical leadership when needed

Patient & Family Support

Provide education regarding transition expectations
Assist families navigating movement between care settings
Reinforce discharge instructions and follow-up plans

Required Qualifications

Active Licensed Practical Nurse (LPN) license
Minimum 2–3 years experience in skilled nursing facility or nursing home setting
Direct experience with:
- hospital transfers
- admissions/readmissions
- discharge coordination
- change-of-condition workflows
Strong understanding of post-acute documentation requirements
Ability to communicate effectively across multidisciplinary teams
Preferred Qualifications
Experience working with:
- post-acute provider groups
- medical directors
- hospital case management teams
Familiarity with:
- INTERACT tools
- CMS readmission initiatives
- QAPI reporting
- EMR navigation across multiple systems
Prior care coordination or navigator experience

Quick Apply

Refine Your Search

nurse navigator jobs in edmond ok

Nurse Navigator

Part-time RN Nurse Navigator - Meinders Center for Movement Disorders

RN Navigator - Registered Nurse - Oncology - Part Time

Nurse Navigator - Adult Endoscopy

Field Registered Nurse Case Manager - Optum Care at Home, Oklahoma City Metro area

RN Care Navigator - Baptist Pulmonary Clinic

Electrophysiology Nurse Navigator - Adult Cardiovascular Clinic