Care Navigator - Population Health

Job Summary

Oversees care management and coordination activities for patients of a primary care practice.

Job Responsibilities

• Works with clinical teams as a resource on care management of patients including pre-visit planning workflow to ensure care completion prior to visit and after-visit summary review with patients when appropriate.
• Involves the patients in activities to improve their health (patient engagement) and educates patients about self management tasks they can undertake to gain greater control of their health status.
• Works with physician leadership to develop protocols and point of care reminders using nationally recognized EBC measures and outcomes. Defines quality measures and outcomes reporting processes. Serves as a resource to clinical staff and providers to establish quality goals using reports.
• Works with IT resources to facilitate registry reporting at the site and documentation of EBC in searchable fields.
• Works with IT resources to coordinate efficient consult request communication and consistent documentation of patient self-management measures, mutually agreed upon care plan that is efficiently available to all, and reporting of progress towards goals.
• Manages assigned panel of chronic care patients (high acuity).
• Develops relationship with patients as an integral member of team by providing follow-up contact with patient as indicated to ensure compliance with recommendations--medications, lab/x-ray, specialist visits, PCP visits, dietitians, CDE, etc. Manages many aspects of the patient's care including referral to specialists, hospitalizations, ER visits, ancillary testing, and other enabling services.
• Provides telephone advice per protocol and handles urgent and emergent calls.
• Works with patient and patient's care team to coordinate change readiness, needs assessment and develops an individualized treatment care plan.
• Assists patient in setting SMART goals for self-management, teaching them how to do self-management tasks, and report abnormal findings to their physician team.
• Collaborates with the patient, physician, and other care team members in assessing the patient's progress toward individual health care goals.
• Assesses barriers when patient has not met treatment goals, is not following treatment plan of care, or has not kept important appointments.
• Oversees the development, procurement, and adoption of patient self-management educational resources used by the primary clinical teams.
• Collaborates with payer Care Managers for additional services when appropriate.
• Develops a list of medical supply and community resources available to patients and maintains collegial relationships with the entities used most frequently.
• Works with consulting physicians, hospitals, emergency department, and other frequently used healthcare sources to clarify roles, develop effective, efficient, and timely communication between primary care physician (PCP) and these entities.
• Facilitates physician leadership to develop written agreements with consulting physicians, key facilities, and community resources to define the roles and method of communication.
• Coordinates consultations and/or referrals, hospital/emergency department, community resources follow-up and tracking process for the practice; works to have clerical component done by appropriate clerical staff whenever possible.
• Develops workflows and protocols within the individualized treatment care plan that ensures emergency department, hospital, and community resource follow-up.
  
  

Qualifications

• Associate's degree or higher or Diploma in Nursing required upon hire
• No experience required
• RN - Licensed as a Registered Nurse. Eligible to practice nursing in the State of Kentucky required upon hire AND
• BLS - Certified as a Basic Life Support Healthcare Provider required within 45 days of employment in this position
  
  

Skills and Attributes

• Requires critical thinking skills and decisive judgment.
• Works under minimal supervision.
• Must be able to work in a stressful environment and take appropriate action.
  
  

Physical Demands

• Standing: Occasionally
• Walking: Occasionally
• Sitting: Frequently
• Lifting 0-25 lbs: Rarely
• Lifting 25-75 lbs: Never
• Lifting over 75 lbs: Never
• Carrying 0-25 lbs: Rarely
• Carrying 25-75 lbs: Never
• Carrying over 75 lbs: Never
• Pushing/Pulling 0-25 lbs: Rarely
• Pushing/Pulling 25-75 lbs: Never
• Pushing/Pulling over 75 lbs: Never
• Climbing: Rarely
• Bending/Stooping: Rarely
• Kneeling: Rarely
• Crouching/Crawling: Rarely
• Reaching: Occasionally
• Talking: Frequently
• Hearing: Occasionally
• Repetitive Foot/Leg Movements: Never
• Repetitive Hand/Arm Movements: Frequently
• Keyboard Data Entry: Frequently
• Running: Never
• Vision: Depth Perception: Frequently
• Vision: Distinguish Color: Frequently
• Vision: Seeing Far: Frequently
• Vision: Seeing Near: Frequently
  
  

Owensboro Health Core Commitments

INTEGRITY - We conduct ourselves with a high level of responsibility, reliability and honesty because we take seriously the trust of our patients and coworkers.

RESPECT - We value and accept the unique talents and contributions of every patient, customer and team member in the Owensboro Health community.

TEAMWORK - We build a spirit of connectivity and fellowship by striving together to overcome obstacles, surpass goals, celebrate accomplishments and plan the future.

INNOVATION - We foster original ideas and creative solutions that improve our daily work and promote the mission of Owensboro Health.

SERVICE - We focus on service to patients, customers and team members by anticipating their needs, thoughtfully meeting those needs and continually improving the quality of everything we do.

EXCELLENCE - We reach beyond basic expectations to expand our knowledge and awareness, produce exceptional work and provide outstanding service.