Chronic Care Nurse Navigator

Austin Regional Clinic: ARC•Round Rock, TX

3d•Onsite

About The Position

Austin Regional Clinic has been voted a top Central Texas employer by our employees for over 15 years! We are one of central Texas’ largest professional medical groups with 35+ locations and we are continuing to grow. We offer the following benefits to eligible team members: Medical, Dental, Vision, Flexible Spending Accounts, PTO, 401(k), EAP, Life Insurance, Long Term Disability, Tuition Reimbursement, Child Care Assistance, Health & Fitness, Sick Child Care Assistance, Development and more. For additional information visit https://www.austinregionalclinic.com/careers/

Requirements

Graduate of accredited nursing school and one (1) or more years working in direct patient care in clinical environment; or a Bachelor of Science in Health Education with one (1) or more years of experience working in direct patient care.
Ability to handle multiple projects simultaneously
Excellent customer service skills.
Excellent interpersonal & problem solving skills.
Ability to work in a team environment.
Ability to engage others, listen and adapt response to meet others’ needs.
Ability to align own actions with those of other team members committed to common goals.
Excellent computer and keyboarding skills, including familiarity with Windows.
Excellent verbal and written communication skills.
Ability to manage competing priorities.
Ability to perform job duties in a professional manner at all times.
Ability to understand, recall, and communicate, factual information.
Ability to understand, recall, and apply oral and/or written instructions or other information.
Ability to organize thoughts and ideas into understandable terminology.
Ability to apply critical thinking skills in performing job.
Familiarity with community agencies and with how to make appropriate referrals to them.
Licensed Registered Nurse in the State of Texas.
Basic Life Support Certification (BLS).

Nice To Haves

BSN degree
experience in case management, home health, or administrative experience.
One or more years working at ARC.
Bilingual in English and Spanish

Responsibilities

Reviews risk stratification reporting to prioritize patients for clinical outreach.
Contacts targeted patients, develops plans of action, ensures physician’s care plan is followed, and monitors status of these plans.
Attends patient visits with the providers, as needed.
Develops trusting relationships with patients and their families.
Works collaboratively with primary care providers and clinic staff.
Supports Medicare Wellness provider staff, as needed.
Utilizes Healthy Planet, the Population Health module of ARC’s EPIC system, to document patient’s current health status, plan of care, and intervention outcomes.
Provides patients with education regarding their chronic health conditions and medications.
Motivates and empowers patients to follow through on their health goals.
Works with health plan resources to maximize patient benefits.
Ensures patient’s medical record is an accurate and complete reflection of their health status.
Works in conjunction with case managers as well as home health and hospice teams to ensure patients are properly transitioned from inpatient facilities back to their homes.
Suggests community resources which might benefit patients and contributes information learned to the shared community resources directory.
Performs other duties as assigned.