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Sutter Health Nurse Navigator, Cancer Center in San Mateo, California

Position Overview:

The Oncology Nurse Navigator (ONN) is a professional RN with oncology specific clinical knowledge who offers individualized assistance to patients, families and caregivers to help overcome health care system barriers. The ONN enhances the patient experience and improves the clinical outcome for patients by providing a seamless navigation process throughout the cancer continuum of care. The ONN is responsible for collaborating with physicians and members of the interdisciplinary teams to triage, coordinate, and consistently manage patient care by educating the patient and serving as a point of contact for patients and families. The ONN participates in strategic initiatives within the Cancer Program Leadership/Oncology Service Line to include developing, implementing and monitoring navigation activities and sustainability, facilitates shared decision making and patient engagement by forming trusting relationships and addressing patients' communication and health literacy needs, while helping them integrate their values and preferences into treatment decisions. The ONN works for and promotes positive outcomes for patients, providers and the Sutter health care system.



  • Registered Nurse with an active license in the State of California

  • A Bachelor’s degree in Nursing or a related field is preferred

  • ONCC Oncology Specific Certification (may include OCN, AOCNS, CBCN, AOCNP, AOCN, CPON, BMTCN, CPHON) required within one year of hire

Skills and Knowledge:

  • Knowledge of medical terminology required

  • Ability to ensure follow through with responsibilities and communicate with a varied level of health care staff

  • Knowledge of third party reimbursement helpful

  • Excellent verbal and written communication skills

  • Microsoft Office software experience required, including Excel and Word

  • Experience working in an EHR, EPIC preferred


  • Two years of Oncology Nursing experience required

Principal Accountabilities:

Coordinates patient care through the point(s) of cancer continuum specified above by assisting with timely access to care, coordinating/facilitating appointments and services, and accompanying patients to appointments as needed:

i. Facilitates timely coordination of appointments/services

ii. Meets with patient by phone or in person “within designated time” following “designated event” and follows patient per facility-specific guidelines

iii. May include meeting with the patient in both acute and non-acute Sutter Health locations

iv. Coordinates appointments, if applicable, for diagnostic testing, services, and with providers to ensure timely delivery of diagnostic and treatment services. May include accompanying patients to appointments (particularly if there are multiple barriers to care) and/or, providing clarification and literacy-level appropriate education related to the visit

Provides care coordination, symptom management support, guidance, education and advocacy across care settings:

i. Discusses physician visits with patients and families and answers questions

ii. Provides and reinforces education re: treatment, care plan, symptom management, and survivorship concerns

iii. Facilitates shared decision making and patient engagement by forming trusting relationships and addressing patients’ communication and health literacy needs, while helping them integrate their values and preferences into treatment decisions.Provides anticipatory guidance related to the cancer journey for patients and families

iv. Empowers patients with education and knowledge to help improve patient outcomes and satisfaction

Assesses patients’ current and future needs, provides patient access to resources (internal and external), facilitates patient needs assessments, including distress screenings and acuity scales; coordinates/facilitates appropriate referrals:

i. Assesses for and identifies patient/family needs and matches unmet needs to appropriate resources during care continuum, based on clinical guidelines and evidence based practices.

ii. Assesses for and works to mitigate barriers to care. Assists patients with access concerns (for screening, diagnosis, and/or treatment, as appropriate) and assists with paperwork as needed

iii. Makes referrals for services based on patient/family needs—i.e., education, finances, psychosocial, survivorship, transportation, child care, lodging.

iv. Facilitates access to physicians and services.

v. Facilitates appropriate medical record availability at scheduled appointments as needed. vi. Facilitates language translation or interpretation services. vii. Facilitates financial assessment and referrals along with assisting with completing forms as needed.

viii. Facilitates linkages to follow-up services

ix. As appropriate, facilitates screening for and access to clinical trials, molecular testing and/or genetic counseling x. Builds partnerships with local agencies and groups (e.g., referrals to other services and/or cancer survivor support groups)

xi. Facilitates distress and acuity screening and makes appropriate referrals

Establishes and maintains close collaboration with providers and the cancer care team to communicate effectively ensuring seamless patient care and care coordination:

i. Communicates and collaborates with involved physicians and staff members to facilitate individualized patient care plans and communication between cancer care disciplines

ii. Maintains communication with patients, families, and health care providers to monitor patient satisfaction with the cancer care experience

iii. Ensures that navigator functions and activities remain within scope of defined role

iv. Provides triage and support services (e.g., symptom management, emotional support, education, resource referral) for patients//families in collaboration with attending physicians and the cancer care team

Actively participates in multidisciplinary conference, assisting with preparing conference materials and providing patient follow-up as needed:

i. Actively participating in multidisciplinary care patient presentation and care planning

ii. Assists with coordination of multidisciplinary conference(s) as needed

iii. Assists with patient follow-up as needed

iv. Assists with and/or attends cancer conferences

Tracks navigation program metrics and quality indicators, documents patient interactions and progression, and communicates navigation activities to physicians and the cancer care team:

i. Assists with tracking, documentation, and outcome reporting for navigation services

ii. Assists with ongoing navigation program assessment and identification of process improvement opportunities

iii. Assists with and/or attends meetings for Sutter Health accreditation endeavors.

iv. Assists with annual accreditation requirements related to navigation and as directed by administration

Participates in community health promotion and awareness programs:

i. Conducts health promotion and awareness programs in community as appropriate

ii. Attends community health fairs and screenings; provides community education presentations as appropriate

iii. Facilitates/attends support groups as appropriate

iv. Conducts and/or assists with a Community Needs Assessment at least once every three years to meet the American College of Surgeons Commission on Cancer accreditation requirement

v. Teaches health topics, including cancer risk reduction, to those interested within the community

vi. Facilitates and/or attends support groups

Service Standards:

Consistently exhibits behaviors set forth in the attached Sutter Health Codes of Conduct

Communication (Oral and Written):

i. Consistently communicates with patients, physicians and other Sutter Health staff in a courteous, professional manner that reflects the desired service outcomes of the department

ii. Prepare patient information materials as requested

iii. Maintains confidentiality of patient information at all times


i. Ability to prioritize goals and work accurately and efficiently


i. Participate in ongoing quality assessment/improvement, ensuring that there is a continuous process of measuring and enhancing quality

ii. Consistently demonstrates Customer Service principles in daily practice • Must be detail-oriented and possess strong organizational skills

iii. Must possess excellent follow-up and follow through skills

iv. Participate in ongoing education opportunities and training

Sutter Health Citizenship:

i. Adheres to all Medical Center policies and procedures (i.e. Administrative and Human Resources), practices safe work habits, and engages in good business standards and practices

Organization: Mills-Peninsula Health Services

Employee Status: Regular

Benefits: Yes

Position Status: Exempt

Union: No

Job Shift: Day

Shift Hours: 8 Hour Shift

Days of the Week Scheduled: Monday-Friday

Weekend Requirements: None

Schedule: Full Time

Hrs Per 2wk Pay Period: 80

Applications Accepted: All Applications Accepted

All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, marital status, sexual orientation, registered domestic partner status, sex, gender, gender identity or expression, ancestry, national origin (including possession of a driver's license issued to individuals who did not present proof of authorized presence in the U.S.), age, medical condition, physical or mental disability, military or protected veteran status, political affiliation, pregnancy or perceived pregnancy, childbirth, breastfeeding or related medical condition, genetic information or any other characteristic made unlawful by local, state, or federal law, ordinance or regulation. External hires must pass a background check/drug screening. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state, and local laws, including but not limited to the San Francisco Fair Chance Ordinance.