Chronic Care Nurse Navigator

External Brand•Pflugerville, TX

About The Position

The Chronic Care Nurse Navigator coordinates health care services for patients with complex health conditions and serves as an educator and advocate. Working with the Primary Care Provider, the Nurse Navigator uses shared decision making and personalized goal setting to develop care plans intended to optimize patients’ overall health and wellbeing. The role involves building trusting relationships with patients and families, encouraging their engagement with the care plan, and recommending screenings and follow-up care based on evidence-based medical guidelines. The Nurse Navigator collaborates with clinical and administrative departments to support comprehensive, high-quality care while maintaining compliance and confidentiality and promoting the organization’s mission and philosophy.

Requirements

Graduate of an accredited nursing school and at least one year of direct patient-care experience in a clinical environment, or a Bachelor of Science in Health Education and at least one year of direct patient-care experience.
Licensed Registered Nurse in the State of Texas.
Basic Life Support (BLS) certification.
Ability to handle multiple projects simultaneously and manage competing priorities.
Excellent customer service, interpersonal, problem-solving, verbal communication, and written communication skills.
Ability to work in a team environment, engage others, listen, and adapt responses to meet others’ needs.
Ability to align actions with those of team members committed to common goals.
Excellent computer and keyboarding skills, including familiarity with Windows.
Ability to perform job duties professionally at all times.
Ability to understand, recall, and communicate factual information; understand, recall, and apply oral or written instructions; and organize thoughts and ideas into understandable terminology.
Ability to apply critical thinking skills in performing the job.
Familiarity with community agencies and making appropriate referrals.

Nice To Haves

BSN degree.
Experience in case management, home health, or administration.
One or more years working at Austin Regional Clinic.
Spanish speaker; bilingual English and Spanish preferred.

Responsibilities

Review risk stratification reports to prioritize patients for clinical outreach.
Contact targeted patients, develop plans of action, ensure the physician’s care plan is followed, and monitor plan status.
Attend patient visits with providers as needed.
Develop trusting relationships with patients and their families.
Collaborate with primary care providers and clinic staff.
Support Medicare Wellness provider staff as needed.
Use Healthy Planet, ARC’s Population Health module in EPIC, to document patients’ health status, care plans, and intervention outcomes.
Educate patients about chronic health conditions and medications.
Motivate and empower patients to follow through on health goals.
Work with health plan resources to maximize patient benefits.
Ensure patients’ medical records accurately and completely reflect their health status.
Coordinate with case managers, home health, and hospice teams to support transitions from inpatient facilities to patients’ homes.
Suggest community resources that may benefit patients and contribute information to the shared community resources directory.
Perform other duties as assigned.