Care Coordination Navigator

Parrish Medical Center•Titusville, FL

About The Position

Under the supervision of Director of Case Management, the Care Coordination Navigator works in collaboration and continuous partnership with the identified patient populations including but not limited to chronically ill or “high risk” patient populations. The Care Coordination Navigator will work with patients, caregiver/family, clinical, hospital, specialty providers and staff, and community resources in a team approach to promote timely access to appropriate care, increase preventative care utilization, reduce hospital readmissions and emergency room utilization, increase comprehension and understanding or medical conditions, promote adherence to care plans, increase continuity by managing tertiary providers through seamless transitions in care, increases awareness and abilities for patients to self-manage, and connect patients with relevant community resources. The Care Coordination Navigator work directly with Parrish Medical Center, Parrish Medical Group and Parrish Health Network to coordinate patient satisfaction enhance quality initiatives and reduce health costs. The Care Coordination Navigator will identify and initiate contact with the identified patient population; provide continuous follow up with patients at need in a variety of settings and coordinate care with the patient, caregiver/family, in-hospital team, community providers, and community resources via secured mail, phone calls, text message, in-person visits, and other means of communication. The position shall exemplify the desired Culture of Choice® and philosophies of Parrish Healthcare.

Requirements

Bachelor’s Degree required, Master’s Degree preferred. RN required.
Minimum of 3 to five years healthcare experience required, preferably with case management or community health experience. Experience with Care coordination model preferred. Experience interacting with Case Management helpful.
State of Florida RN License.
Valid Florida Drivers Licenses FDL valid Motor Vehicle Record (MVR) that is acceptable to PMC’s corporate automobile insurance carrier. License will be screened prior to employment and at least annually thereafter.

Responsibilities

In coordination with PHN, PMC and PMG Leadership, works to proactively manage healthcare costs by identifying and coordinating management of health conditions of the identified patient population.
Coordinates and collaborates with Parrish health System entities in the community and the hospital to identify persons appropriate for Care Navigation through the use of EMR and analytical systems.
Collaborates, grows and maintains working relationships with community resources to meet the healthcare needs of individuals.
Reviews available information obtained by healthcare team members from multiple care settings and EMR. Consider physical, cultural, psychosocial, spiritual, educational, and age specific needs of the person to meet the patient’s healthcare needs.
Performs follow-up visits or calls to patients and providers regarding their experience and issue resolution and reviews patient data/demographics and other pertinent information to reflect changing patient needs and provide input on update as needed by:
Assessing unmet health and social needs
Developing care plan with patient, caregiver/family, and providers
Monitor adherence to care plan, evaluate effectiveness, patient progression of care, and facilitate changes as needed
Engage patient and caregiver/family to adhere to care plan and self-management goal.
Serves as main contact point, advocate, and informational resource for patients, care team, family/caregiver, payers and community resources.
Facilitates patient access to appropriate medical and specialty services.
Educates patient and family about relevant community resources and assist with the referral to these resources.
Facilitates and attends meetings in regard to quality care initiatives, as needed.
Assists with the identification of “high risk” patients (the chronically ill and those with special health care needs) and add these to the patient registry (or flag in EHR).
Cultivates and supports primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
Attends all Care Coordination meetings and training courses/webinars. Works with Leadership and work groups to create work plans providing necessary feedback for the improvement of the Care Coordination Program.
Ensures compliance with all federal, state and local laws and regulations
Performs similar or related duties as assigned.
Knows fire, disaster and safety procedures and regulations as it pertains to the work area