Title: Registered Nurse Patient Care Navigator
FSLA: Non-Exempt
Reports To: Director of West Operations
Mission: To Provide the residents of our communities the highest quality, state-of-the-art and comprehensive Orthopaedic care.

Main Function: As a member of the care team, the Patient Care Navigator is responsible for working collaboratively with other team members to assure the safe, timely and accurate delivery of patient care. The Patient Care Navigator maintains all patient confidentiality and HIPAA rules and regulations.  Supports Tucson Orthopaedic Institute’s mission, values, vision, goals and objectives.

Customer Service:

  • Operate within the concept of patient focused care
  • Anticipate patient needs
  • Deliver caring timely service with positive body language
  • Responds promptly to patient needs and requests
  • Greet patients at every stage of the visit
  • Responds promptly to Physician and team member requests and inquiries
  • Participates as an active, positive member of the TOI team

Duties and Responsibilities:

  • Understanding of the Bundled Payment Program design, implementation, management, monitoring, and reporting requirements.
  • Knowledge of CMS regulations and guidelines for Bundled Payment Initiatives
  • Obtain telephonic health assessments and provide coordination of care for orthopaedic surgical patients.
  • Provide patient and caregiver education on surgical processes and expectations of the health care delivery system.
  • Gather clinical information from EHR and other available health assessments to determine risk stratification. (These include a comprehensive assessment of physical, emotional, psychosocial, and environmental needs of the patient)
  • Assess the patient’s mental and physical condition, and discuss the problems and treatment options with patient’s care team when flagged by call center.
  • Document clinical assessments and care plans in case management system.
  • Collaborate with multidisciplinary team in the acute and outpatient settings to identify patient needs such as home health care, DME, physical therapy, and community services.
  • Manage patient treatment plans at pre-determined intervals and be proactive to identify any gaps or barriers in the patient care plan.
  • Evaluate plan of care and revise on an ongoing basis as determined by the patient’s health status; communicate changes to all other disciplines involved in the patient’s care.
  • Communicate with providers and multi-disciplinary care team to facilitate transition of services through the continuum of care.
  • Provide excellent customer service to internal and external customers through prompt response and courteous communication within 24 hours of the request.
  • Remain flexible and responsive when changes occur in patient activity and workload.
  • Work with service lines to continually manage best clinical practices.
  • Assists with the development and maintenance of clinical protocols.
  • Maintain confidentiality of all patient information per HIPAA and TOI guidelines.
  • Performs all other duties as assigned
  • Maintains records as directed on all BPCI patients
  • Assists with staffing and shift coverage for navigation team


  • Register Nurse (RN)
  • Minimum of 2-3 years orthopaedic experience in a hospital setting or telephonic case management experience required
  • Prefer candidates that have experience with discharge planning and outpatient care coordination
  • Orthopaedic and Geriatric experience preferred
  • Proficient computer skills
  • Excellent interpersonal and customer service skills
  • Ability to work independently
  • Deep understanding of clinical competencies associated with orthopaedics.
  • Ability to evaluate and establish protocols.
  • Ability to work as a team player with individuals both in and outside of the organization.
  • Continued awareness of clinic delivery trends; ability to evaluate implementation and maintenance of programs.
  • Knowledge of Federal, State and Local laws and regulations pertaining to the activities and functions of the clinic.
  • Excellent verbal and written communications skills.

Mental/Physical Requirements:

  • Ability to work well under pressure with diverse groups of professionals and physicians
  • Ability to communicate written and oral ideas and plan effectively
  • Requires good communication and organizational skills
  • Requires reasoning ability and good independent judgment
  • Must be sensitive to cultural and bilingual issues
  • Requires working under stressful conditions and irregular hours
  • Requires working with frequent interruptions
  • Must be able to interact and communicate in English, both orally and written, with all levels of staff, physicians, patients, and families in an effective manner, exhibiting tact, enthusiasm, and patience
  • Must be able to be sensitive to cultural and bilingual issues
  • Stands or sits to perform job duties when indicated. Requires tolerance of standing or sitting posture up to (4 hours) continuously, for a total of up to (10 hours) per (12 hours)
  • Required to operate computer keyboard, mouse, and monitor for a total of up to (8 hours) per (12 hours)

Working Conditions: Risk of occupational exposure to blood and other potentially infectious materials (OPIM). Possible risk of physical injury due to moving machinery and supplies.  This is a safety sensitive position.

All positions with Tucson Orthopaedic Institute are to demonstrate due care in the use and communication of patients’ protected health information.  It is every employee’s principal job function to ensure patient confidentiality and failure to maintain confidentiality may, and will, result in sanction and/or discharge.