Care Navigator - Population Health

Summary

Implements care plans that are specific to each patient's physical, mental, and social needs based on medical and pre-surgical clinical assessments. Ensures smooth transitions and evidence-based disease management for select populations prior to hospitalization and/or a segment of time post-discharge. Works collaboratively as part of a multi-disciplinary team to provide patient and family education and navigation across the continuum of care.

Job Duties

• Identifies patients not meeting clinical goals or important quality metrics and arranges follow-up per protocol, as appropriate.
• Reviews and updates medication list and accurately documents known allergies in the electronic health record (EHR).
• Utilizes registry and other data along with published evidence to assist with the point of care decision making. Supports quality improvements, pilot participation, and other research activities.
• Identifies actual or potential variances in standards of care and system problems that could lead to errors, delays in care, complications, or increased cost.
• Establishes and maintains external relationships with hospitals, rehabilitation facilities, and other post-acute care facilities.
• Provides care navigation services to specialty populations, inclusive of LVHN Specialty Institutes and BPCI-A.
• Collaborates with patient/family in establishing mutual goals based on the patient's needs and problems.
• Identifies issues related to the healthcare system, transportation, financial, and/or psychological barriers and works collaboratively to problem solve, coordinate services, and advocate for patients/families.

Minimum Qualifications

• Bachelor's Degree in Nursing. Experience in lieu of Bachelor's degree may be considered.
• 5 years experience working as a registered nurse (RN).
• 2 years previous experience in case management, disease management, home health care, hospital, or physician office setting.
• 2 years prior electronic medical record (EMR) experience.
• Ability to set priorities to coordinate care plan efficiently.
• Utilizes effective strategies for interacting with persons from diverse backgrounds.
• Ability to recognize the role of cultural, social, economic, and behavioral factors in accessibility, availability, acceptability, and delivery of public health services.
• Knowledge of computer applications and analytical tools.
• RN - Licensed Registered Nurse_PA - State of Pennsylvania upon hire.
• CACRN - Certified Ambulatory Care RN - State of Pennsylvania within 3 years or CCCTM - Cert Care Coord-Transition Mgt MSNCB - State of Pennsylvania within 3 years.

Preferred Qualifications

• Master's Degree Nursing.
• 2 years condition- or population-specific experience (Orthopedics, Cardiac, Pulmonary, GI, Pediatrics).