Nurse Navigator- TCM, CCM, ACO, Medicare Annual Wellness Visits and Population Health Full-Time-36 hours per week

Howard County Medical Center•St Paul, NE

11h•Onsite

About The Position

Howard County Medical Center invites applications for the position of Nurse Navigator at its location in St. Paul, Nebraska. The Nurse Navigator coordinates patient-centered care across the continuum, focusing on care transitions, chronic disease management, preventative care, quality outcomes and population health initiatives. This role collaborates with providers, care teams, community resources and patients to improve health outcomes, reduce hospital admissions, increase patient engagement and support value based care programs with supervision of the medical staff. Mileage Reimbursement for candidates outside a 25-mile radius from the St. Paul location!

Requirements

Current Nebraska Registered Nurse Licensure
Three to five years of nursing experience is required, preferably in a Rural Health setting.
Experience with computer and data collection is required.
Ability to add, subtract, multiply, and divide
Ability to generate, read, interpret, and take action as it relates to basic financial statements, national and state regulations, operational and maintenance and organizational policies/procedures
Ability to write reports and correspondence
Ability to effectively communicate
Ability to work cooperatively and communicate effectively to maintain good working relationships
Ability to work with skill in identifying problems, making frequent decisions regarding method of performance

Nice To Haves

TCM, CCM, ACO, Medicare Annual Wellness Visits and Population Health experience
Experience in a Rural Health setting

Responsibilities

Conduct patient outreach, assessments, care planning, patient education and follow-up to support preventative care, transitions of care and chronic disease management.
Transitional care management-Coordinate care transitions, complete medication reconciliation, patient education, follow up care, referrals and community resources.
Chronic care management-Provide ongoing care coordination, develop and maintain careplans, monitor chronic conditions and treatment adherence.
Conduct Medicare Annual Wellness Visits in collaboration with provider to identify and address gaps in care, preventative screenings and quality measures.
Educate patients and caregivers to promote self-management of chronic conditions and improve health outcomes.
Support initiatives related to value based care contracts and shared savings programs including monitoring quality metrics and care gaps, collaborating with providers and care team to close care gaps and improve quality metrics.
Maintain accurate documentation and ensure compliance with CMS and organizational requirements.
Utilize Excel spreadsheets, reports and population health databases to track patient outreach, quality measures and care management activities
Provide additional back up help for the medical clinic.
Implement health education in the community.
Performs all other duties as assigned.