Rn/Lpn/Cma - Patient Care Navigator

Horizon Health•Paris, IL

8d•Onsite

About The Position

Horizon Health is a Critical Access, Rural Health Facility with a 25-inpatient-bed hospital in Paris, Illinois, and outpatient Family Practice and Specialty Clinic settings in Paris and surrounding cities. The organization has served Edgar County since 1968 and continues to expand its services and locations. The Patient Navigation Nurse is responsible for outreach, scheduling, and care management for assigned patients in support of ACO value-based goals. The role establishes and maintains relationships with physicians, clinical staff, patients and caregivers, payers, and community resources. It also uses computer programs and platforms to gather and analyze data related to population health program goals and objectives. The position requires RN, LPN, or CMA licensure. Patient Navigation and ACO experience are preferred. The schedule is Monday through Thursday, 7 a.m. to 4 p.m. Pay varies by credential and applicable years of experience: RN, $23.855–$38.168 per hour; LPN, $18.122–$28.329 per hour; CMA, $15.750–$25.216 per hour.

Requirements

Current RN, LPN, or CMA licensure.
Demonstrated verbal and written communication skills.
Conflict-resolution skills.
Interdisciplinary collaboration skills.
Care-management skills.
Creative problem-solving and critical-thinking skills.
Knowledge of community resources.
Current BLS certification, or ability to obtain it within 30 days of hire.

Nice To Haves

Experience with Patient Navigation.
Experience with ACOs.

Responsibilities

Use motivational interviewing to build trust, clarify patient goals, explore ambivalence, and support positive health-management steps.
Review target patient lists and disease registries to identify high- and emerging-risk patients and evaluate their suitability for Chronic Care Management programs.
Perform assigned Medicare Wellness Visits.
Manage assigned Chronic Care Management caseloads, including coordinating treatment, completing assessments, developing care plans, monitoring medication compliance, and communicating with primary care providers and staff.
Complete Transition of Care outreach calls within established guidelines and arrange timely, appropriate follow-up with primary care or specialty providers.
Document outreach efforts and outcomes accurately and promptly to support gap closure.
Review medication adherence gap reports daily; contact patients about potential barriers, provide medication education, and intervene to promote adherence.
Connect patients with Medicare Advantage Medication Therapy Management programs as required by contracts and quality measures.
Coordinate Remote Patient Monitoring during clinic hours by receiving and resolving escalations from the RPM provider.
Identify appropriate CCM/PCM and TOC patients for referral to the RPM program.
Identify barriers to preventive screenings, annual wellness visits, and follow-up care, and help patients overcome them.
Use knowledge of community resources to help patients address socioeconomic barriers to care and maintain a database of community and payer resources.
Maintain accurate records and provide reports to managers, directors, and others as required.
Contribute to closing gaps in care.
Participate in meetings and collaborate with internal and external stakeholders to develop and implement strategies for program goals.
Perform other duties as assigned in support of hospital goals and objectives.