Care Navigator - Population Health

Owensboro Health•Owensboro, KY

23h•Onsite

About The Position

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

Requirements

Requires critical thinking skills and decisive judgment.
Works under minimal supervision.
Must be able to work in a stressful environment and take appropriate action.
No experience required
Bachelor’s degree or higher in Nursing required upon hire
RN - Licensed as a Registered Nurse. Eligible to practice nursing in the State of Kentucky required upon hire
BLS - Certified as a Basic Life Support Healthcare Provider required within 45 days of employment in this position

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.