Job Description

Overview

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The Peterborough Family Health Team (PFHT) is seeking a patient-centered and experienced primary care registered practical nurse to join our Clinical Support Services team as a Nurse Navigator.



Reporting to the Patient Services Supervisor, the RPN/Nurse Navigator is an integral part of a multi-disciplinary team who provides continuous support and advocacy for patients from initial assessment through to community engagement. This position works to enhance patients' social determinants of health by facilitating navigation of care pathways and fostering collaboration with clinical teams and community partners. In addition, the RPN/Nurse Navigator supports the PFHT Health Clinic in a clinical capacity, working alongside Nurse Practitioners and Family Physicians to provide day-to-day patient care within the clinic setting.



This is a permanent, full-time position (1.0 FTE; 37.5 hours per week) based in Peterborough, Ontario

Responsibilities

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Navigation & Support Responsibilities

Collaborate with patients, primary care providers, and community resources to improve access to support services and coordinated care. Assess social determinants of health and help patients establish care goals based on their needs and eligibility for services. Provide direct patient support including follow-through on care plans, phone outreach, education, assistance with applications/forms, and general system navigation. Advocate on behalf of patients to improve access and outcomes, especially during transitions of care. Build and maintain strong relationships with patients, clinicians, and external partners to support integrated and holistic care. Identify appropriate community resources and connect patients through referrals, collaboration, and advocacy. Educate patients, caregivers, clinicians, and community stakeholders on available internal and external services. Promote communication and continuity during transitions of care, recognizing and addressing gaps where necessary. Enhance patient and caregiver capacity for self-navigation through education, system knowledge, and empowerment strategies. Collaborate with primary care providers, patients/families and community resources to assist patients with access to support services Assess - identify patient needs, create goals around social determinants of health, review eligibility criteria for services needed Build relationships with patients, clinicians & community partners Identify community resources and connect patients to them through referral, advocacy and collaboration Provide direct patient support (i.e. support patient follow-through, phone calls, provide information regarding processes and systems, assist with the completion of applications/forms, general advocacy, etc.) Provide supportive counseling and coaching as needed Support patient-centered care and when necessary, act as an advocate to facilitate positive patient outcomes Provide information and education to patients, clinicians and community partners regarding services available (within and external to PFHT) Work within an integrated health care philosophy to improve communication and coordination of patient care Promote opportunities to improve communication during patient transitions - recognizing and identifying gaps as required. Build the capacity of patients and caregivers to navigate the healthcare system independently

Clinical Responsibilities

Obtain a history of presenting health issue(s) and conduct comprehensive and focused health assessments. Perform physical evaluations and gather relevant health histories, considering psychosocial, emotional, cultural, and spiritual dimensions of care. Use and adapt clinical assessment tools based on each patient's unique needs. Complete and document thorough medication assessments, including prescription, over-the-counter, and alternative therapies; regularly review medication lists and assess adherence. Incorporate objective data (e.g., lab results, diagnostics, and specialist reports, past medical history) into overall patient assessment. Apply recognized clinical practice guidelines and evidence-based best practices in screening, monitoring, and evaluating physical and emotional health. Identify potential health concerns and screening needs using critical thinking and clinical reasoning. Document all health assessments and clinical data accurately in the patient record and care summary. Provide telephone and in-person triage according to established protocols and clinical judgment.

Position Requirements

Ability to perform all regular RPN clinical and technical tasks An RPN in good standing, with a diploma, currently registered, according to the requirements of the College of Nurses in Ontario Demonstrated excellent interpersonal communication skills and decision-making ability Ability to work independently and cooperatively in a busy, multi-disciplinary situation Demonstrated proficiency in applicable computer programs Understands, through education and/or experience, how social determinants of health impact health and health equity Demonstrated commitment to principles of anti-racism, anti-oppression, equity and inclusion Problem solving (able to make independent service decisions) Collaboration and teamwork. You enjoy working both independently and as a member of a dynamic team on new and existing services and special projects Knowledge of primary care and a demonstrated understanding of its intersection with the healthcare system A valid driver's license and a reliable vehicle are required, with the ability to drive to various locations dependent on patient visit A clear police vulnerable check Participates in data collection activities as required Ability to lift up to 20 lbs. Flexibility in adjusting to various work hours according to need Ability to remain sitting for considerable periods of time; ability to communicate extensively over the telephone. Assumes other duties as appropriate.

The above responsibilities are not to be considered all-inclusive; they may be assigned other related duties in the interest of efficient operations of Peterborough's Family Health Team.

Qualifications

Diploma in Practical Nursing Registration with the College of Nurses of Ontario and active knowledge of CNO Standards of Practice and Best Practice Guidelines Excellent documentation and time management skills Experience in primary care or community settings preferred Member of WeRPN preferred Knowledge of community resources and relevant legislation (e.g. OW/ODSP, CPP/-D, CFSA, WSIB), preferred Willingness to work in full scope of practice, performing delegated acts through medical directives

Additional benefits of joining the Peterborough Family Health Team

A provincial leader among Family Health Teams in Ontario Excellent team/office environment Multidisciplinary team expertise PFHT provides clinical supervision Organizational commitment to work-life balance HOOPP Pension Plan Optional dental and health benefits Life and disability insurance Healthcare spending account EAP Program

The Peterborough Family Health Team are leaders in advocating for full vaccination against the COVID-19 virus and its variants, for persons who are medically able to receive the vaccination. All applicants should know that PFHT employees are expected to support this position.

Interested candidates can email their resume and cover letter to resumes@peterboroughfht.com by the application deadline.

Application deadline:

July 6th,2025

Hours:

Monday to Friday - some evening work may be required

Expected start date:

July 28th,2025

Job type:

Permanent, 37.5 hours per week

Salary:

$52,104 to $58,656 per year based on full time equivalent

The Peterborough Family Health Team is actively committed to creating a diverse and inclusive workplace and encourages applications from all qualified candidates. The Peterborough Family Health Team offers accommodation for applicants with disabilities in its recruitment processes. We thank all applicants for their interest; however only candidates selected for further consideration will be contacted.