Nurse Navigator (Maysville, Ky)

Interested parties should submit a cover letter and resume via e-mail to: humanresources@welcomehouseky.org

 

Job Title:	Nurse Navigator	Revision Date:	April, 2025
Job Classification:	Medical	Department:	Regional Services East
Location:	Maysville, Kentucky	FLSA Status:	Exempt
Supervisor:	Supervisor of Sutton’s Landing	Supervises:	N/A

 

JOB SUMMARY

Full-time, direct service role focused on building trust and delivering person-centered, trauma-informed care to individuals in permanent housing. Uses motivational interviewing and harm reduction to engage participants and support their well-being.

Works as part of an interdisciplinary team to assess, plan, and coordinate individualized care using evidence-based practices. Collaborates with housing providers, medical staff, social services, and families to develop integrated care plans.

Through the Assertive Community Treatment model, supports transitions out of homelessness, connects participants to housing, health, and social services, and provides on-site primary care and health education for those hesitant to access traditional healthcare.

All duties are carried out in alignment with the core values of Welcome House: Compassion, Advocacy, Integrity, Quality, Leadership, and Community.

 

PRINCIPAL DUTIES & RESPONSIBILITIES 1. Outreach and Clinical Care Deliver comprehensive, holistic primary care through the Assertive Community Treatment (ACT) model, including physical exams and the management of both acute and chronic conditions. Evaluate treatment outcomes and provide ongoing medical recommendations. Review and assess pharmacological treatment plans. Collaborate with program staff to coordinate prescriptions, medical orders, and monitor participants’ overall health status. Partner with healthcare providers and refer participants to appropriate services when needed. Develop, maintain, and regularly update individualized care plans, health records, and required documentation. Conduct monthly reviews of participant medications and treatment plans. Provide health education and promotion to both participants and staff. Advocate for participants as they access and navigate the healthcare system. Work closely with participants and the interdisciplinary team to establish and follow through on individualized service and treatment plans. Coordinate with the team leader to establish a schedule that ensures timely care for all participants. Actively engage eligible participants in medical services both on-site and in the community. Educate and support agency staff in building awareness of local healthcare providers and available community health resources. Serve as a knowledgeable healthcare resource for participants and their families or significant others. Assist in arranging hospitalizations (medical and psychiatric), crisis interventions, and appropriate referrals. Communicate with hospital staff to support continuity of care and effective discharge planning. Perform other related clinical duties as assigned. 2. Internal and External Collaboration Coordinate with service coordinators to help participants access comprehensive support and services. Work collaboratively with the Buffalo Trace outreach team members, Sutton’s Landing team services coordinator, property management and community resources. Identify and engage strategic partners to improve service delivery and reduce access barriers for participants. Foster a culture of shared responsibility by offering respectful, collaborative support to team members and contributing to participant outcomes. Represent Welcome House in a professional manner and act as a liaison with community service providers. Provide training and mentorship to staff regarding nursing procedures and best practices in street outreach. Deliver ongoing staff training on key health-related topics, such as Narcan administration, CPR, and general health and wellness protocols relevant to both staff and participants. 3. Administrative Responsibilities Maintain an up-to-date roster of active program participants. Accurately document and manage participant data and assist the Director and Supervisor of Sutton’s Landing with data collection and reporting. Analyze outcome data and present insights to program leadership as requested. Complete timely data entry in VESTA, within three business days of service delivery. 4. Other Duties as assigned by the Director and/or Supervisor of Sutton’s Landing.

 

QUALIFICATIONS:

          Valid Driver’s License & Automobile Insurance  

Education:

• Bachelor’s degree required
• Licensed as a Registered Nurse in the state of Kentucky;
• Master’s degree in nursing preferred
• Certification by the American Nurses Credentialing Center; preferred

Experience:

• Registered Nurse: 3 years (preferred)
• Nursing: 1 year (required)
• Experience working with the homeless population, desired.

 

Skills/Specialized Knowledge/Abilities:

• Strong leadership, critical thinking, problem-solving, and conflict management skills
• Excellent written and verbal communication
• Compassionate, patient, flexible, and culturally sensitive, especially toward individuals with disabilities and minority populations
• Proficient in engagement practices and mentoring team members
• In-depth knowledge of mental illness, substance abuse, and related community resources
• Skilled in independent and team-based work, with a focus on collaboration and networking
• Experience with dually diagnosed individuals and community-based work preferred
• Valid driver’s license and vehicle access preferred

 

Key Performance Indicators:

• Understands agency vision/mission and how to achieve agency goals
• Understands culture of poverty and works effectively with program participants
• Proficient in-service planning and program participant engagement
• Proficient in documentation and have to ability to train staff
• High Involvement in community partnerships
• Proficient knowledge of Mental Health/Substance Abuse resources
• Proficient in job readiness
• Proficient in assessment
• Participating in leadership responsibilities within income and benefits team and agency
• Ability to understand and contribute to quarterly and annual reporting
• Takes on leadership role in departmental and cross-functional compliance

 

WORKING CONDITIONS:

Working Hours/Environment

• Work sometimes performed in an indoor, 3-floor office building with stairs only and in the community
• Work mostly performed outdoors

 

Tools and Equipment Used

• Personal computer, copier, fax/scanner, phone, and other typical office equipment.

 

Travel

• Average – of 25% of the time.

 

Physical and Mental Demands

• Ability to walk short distances on possibly uneven terrain
• Frequently required to sit at a desk/workstation for long period of time
• Ability to work at a computer terminal for extended periods of time
• Digital dexterity and hand/eye coordination in operation of office equipment
• Ability to speak to and hear employees/program participants  via phone or in person
• Body motor skills sufficient to enable incumbent to move between 3 floors
• Additional Mental Requirements: compare, decide, direct, problem solve, analyze, instruct, interpret
• Minimum lifting up to and above 50 pounds

 

Supervisor’s Acknowledgment:		Date:
Employee’s Acknowledgment:		Date:

 

This job description does not constitute a written or implied contract of employment.  This job description in not intended and should not be construed, to be an exhaustive list of all responsibilities, skills, efforts, or work conditions associated with the job.  Furthermore, the employer reserves the right to revise or change job duties and responsibilities as the need arises.