Care Navigator

Summit Health•Bend, OR

1d•Hybrid

About The Position

The Care Navigator directly supports and promotes the care transitions and social support needs of patients across the continuum of care. S/he also supports quality improvement initiatives through targeted outreach to patients who are not meeting clinical goals. This position collaborates with providers, RN Care Managers, Social Workers and others to facilitate seamless transitions of care, social support interventions, and patient outreach and engagement to close care gaps, with the goal of assuring superior patient experience and quality outcomes. The Care Navigator networks internally with SHM clients and externally to all care settings to obtain needed clinical information, engage and educate patients, identify risk factors for referrals, and perform an integral role in clinical data collection, tracking, trending and reporting on all outcomes.

Requirements

Bachelor’s Degree preferred but not required
Certified Medical Assistant, Licensed Practice Nurse in the State of Oregon, preferred or other relevant clinical experience considered.
2-4 years of relevant work experience in the health care field is preferred
Valid Driver’s License
Must be proficient in computer skills
Must be proficient in Microsoft Office, Excel, Word and Power Point

Nice To Haves

Certified Medical Assistant, Licensed Practice Nurse in the State of Oregon, preferred

Responsibilities

Establishes and maintains external relationships with hospitals, rehabilitation facilities and other post-acute care facilities by: (1) Promoting ongoing collaboration and regular communications with facilities and providers; (2) Conducting & documenting routine/weekly outreach calls to all facilities to gather critical clinical information about admitted patients; and (3) Demonstrating effective relationship-building skills
Works collaboratively with both internal and external entities to facilitate seamless transitions across the continuum of care by adhering to departmental administrative TOC workflow standards.
At time of patient discharge, initiates and completes the TOC process on behalf of client’s providers and ensures a seamless handoff of information to RN Care Managers and other interdisciplinary team members for further follow-up post discharge
Manages low risk patients discharged from an inpatient facility by providing outreach to the patient and adhering to an established care pathway and algorithm designed for the outreach process for low risk patients.
Collaborates with Social Support team and manages the Information, Referral and Assistance inquiries received; ensures that outreach to patient/family member/caregiver is completed in a timely and efficient manner.
Maintains the Social Services Directory.
Supports the Hospitalist Teams in creation of and distribution of the daily inpatient hospitalist census in a timely and efficient manner ensuring all relevant patient information is included in the daily hospitalist census including attribution status.
Tracks “Avoidable Admissions” by receiving email from Hospitalist team identifying a patient that was treated in ER but not admitted to hospital. Follows established workflow of patient case being created and PCP office being notified of need for outreach to avoid recurrent ED visit/hospitalization.
Provide care coordination and social support services as needed.
Identifies patients not meeting clinical goals or important quality metrics and arranges follow-up by protocol, as appropriate.
Uses registry tools to identify and track patients.
Conducts follow-up activities with patients who have not kept important appointments or completed needed diagnostic testing.
Identifies patients and families who would benefit from additional care management /social work support and makes appropriate referrals.
Reviews and updates medication list and accurately documents known allergies in the Electronic Health Record (EHR).
Demonstrates an understanding of prescription control and prescription refill procedures.
Records patient information accurately to support population health initiatives.
Updates data worksheets with outcomes following patient contact and recommendation of needed services and appointments.
Facilitates and arranges new patient and follow-up services per treatment protocol, as appropriate.
Collects, tracks, trends and reports clinical data, as needed, for all Transitions of Care Program patients, Low Risk Care Management patients, Social Support Program patients, patients discharged from ED, and patients requiring outreach for closing care gaps.
Maintains information flow and communications with non-SMG collaborating providers to ensure efficient patient care.
Demonstrates appropriate and timely use of the EMR.
Attends all pertinent departmental meetings and trainings that involve Care Management team, Social Support Program, hospitalist or extensivist workflows.
Assists with special projects as assigned and completes them within the required timelines.
Effectively communicates problems, concerns or issues to the Supervisor and/or Manager appropriately and promptly.