Patient Care Navigator MSW, Transitions of Care

Nevada System of Higher Education

3d•$33 - $49•Hybrid

About The Position

The SW Care Navigator is responsible for the case management and care coordination of his/her population of patients from the time of diagnosis (could be pre-admission or in the ED) to 90 days post-discharge. This position will collaborate with the RN Care Navigator. This position involves helping patients understand their diagnosis, treatment options, and ensure that they are connected with the optimal resources across the continuum of care. The SW Care Navigator will help to identify and address complex family dynamics and other social determinants of health. This role will coordinate discharge planning by facilitating smooth transitions of care while ensuring quality cost-effective patient outcomes. Serves as a liaison between their patient population and all other providers. Will be responsible for key metrics of success, which include improving the overall cost of care, length of stay optimization, reduction in excess days, reduction in SNF utilization and improvement in SNF care transitions, reduction in 30-day readmission rate and ED utilization.

Requirements

Masters Degree Required
2 Years 2+ years of related health care experience.
Discharge planning, case management, home services, ambulatory services working with high risk patients beneficial.
Experience with behavioral health also beneficial.
Able to communicate and work collaboratively with a range of stakeholders and team members
Knowledge of community resources
Experience with Microsoft Office Suite
Strong interpersonal and oral communication skills
Strong computer and data entry skills
Experience with Electronic Medical Record (EMR) platform preferred
Proven leadership skills
Ability to work independently, setting priorities to coordinate care plan efficiently
LCSW strongly preferred
Preferred Or Master’s degree in social work required.
Required Or Clinical certification, such as case management certification, is beneficial.
Required Or Basic Life Support for Healthcare providers (AHA) or CPR/AED for the Professional Rescuer (American Red Cross)

Responsibilities

Connects with patient at the time of diagnosis (either ED or pre-admission) and follows the patient across the hospital stay and 90 days post discharge.
Guides patient and family through the health system from diagnosis, testing, treatment and follow-up care to assist patients with navigating the continuum of care.
Eliminates barriers to patient's access to health care services and facilitates continuity of care/care coordination.
Partners with the healthcare team to ensure clinical decision-making, implementation of recommendations, and discharge planning are timely and appropriate.
Oversees and facilitates effective and impactful interdisciplinary rounds that are structured and standardized.
Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas.
Performs daily coordination between multiple departments, multi-disciplinary team, medical clinics, and community outreach to gain knowledge of patient, assure patient safety, smooth transitions of care, and manage utilization and total cost of care.
Routinely assesses and monitors the patient’s status, needs, and progress by proactively reaching out to the patient/caregiver and ensuring that they are connected to the most appropriate and impactful resources.
Acts as advisor/educator by providing emotional support including goals of care and counseling.
Provides and/or arranges clinical education including medication management, community resources, financial resources, and expert guidance to patients and families to promote their ability to understand and meaningfully participate in the healthcare process and personal decision-making.
Responsible for outreach efforts to establish and maintain positive working relationships with patients, family including multidisciplinary team i.e. physicians, office staff, diagnostic staff, nurses, social services staff, home services etc.
Facilitates appointments for appropriate consultations and support services within established protocols
May need to travel to visit the patient at home.nnects with providers across the care continuum proactively and in a timely way.
Available to his/her assigned patient population 24/7 and participates as part of a call coverage structure.
Participates in handoff processes within the team to ensure that patients are connected to the care navigator program across their care episode.
Participates in the collection and analysis of data to identify under/over utilization; improve resource consumption; promote potential reduction in cost; and enhance quality of care consistent with organization strategic goals and objectives.
Conducting precertification, concurrent, and retrospective utilization management through the application of nationally recognized criteria.
Follows patients throughout the care continuum including emergency room, inpatient admissions, home care, outpatient services and primary and specialized appointments.
Ensures that patients have and keep post-discharge follow-up appointments and that their medications are accurate and appropriately reconciled at each point of care.
Helps patients understand their insurance coverage as well as the post-acute level of care, necessary durable medical equipment required for recovery.
Develops concise patient itinerary for use by the patient and the care team, and documents all communication with the patient so it is visible across the care team
For patients who are discharged to settings other than home, works with the providers and teams at those facilities to ensure patients are meeting goals of care and transitioned efficiently and effectively back to the home setting.
Develops, plans and presents patient education programs and tools and enrolls patients in these programs so they are able to benefit maximally from all of the program elements.
Provides emotional support and counseling to the patient and caregivers
Helps patients understand their insurance coverage as well as the post-acute level of care, necessary durable medical equipment required for recovery
Coordinates and collaborates with inpatient continuum Care Manager while the patient is hospitalized, accepting hand off at the time of discharge.
Completes and documents assessment in accordance with NorthShore and health plan requirements.
Develops, implements, updates individualized care plan for patient until program completion.
Documents in health plan portals as required.
Model behaviors and organizational standard to promote quality, patient safety, and enhanced patient care coordination.
Knowledge of Medicare, Medicaid, and Third party reimbursement (i.e. HMO and Health Plan Benefits).
Actively participates in performance improvement and other approaches. Collaborate with the team members to develop effective work processes that may lead to improvement of work.
Has a good understanding of the goals and expectations so to develop work functions across the team is aligned and synergistic.
Leads regular staff huddles, interdisciplinary rounds, and other meetings to update team and give progress reports.
Uses insights from risk management and patient advocacy to understand opportunities to improve day to day operations of care coordination.
As this job evolves, this role will complete others duties assigned.

Benefits

Premium pay for eligible employees
Career Pathways to Promote Professional Growth and Development
Various Medical, Dental, and Vision options, including Domestic Partner Coverage
Tuition Reimbursement
Free Parking at designated locations
Wellness Program
Savings Plan
Health Savings Account Options
Retirement Options with Company Match
Paid Time Off and Holiday Pay
Community Involvement Opportunities