RN/LPN/CMA PATIENT CARE NAVIGATOR

Horizon Health•Paris, IL

8d•$16 - $38•Onsite

About The Position

Horizon Health is a Critical Access, Rural Health Facility comprised of 25-inpatient beds located in Paris, IL & a multitude of outpatient clinic settings including Family Practice and Specialty Clinics in Paris and surrounding cities. We have been serving residents of Edgar County since 1968 though community education, emergency services, and outpatient care. As we continue to expand our services & locations, our community has grown far beyond Paris. Our rich history and strong community support pave the way for the future of healthcare as we serve you—our family, friends, and neighbors. The Patient Navigation Nurse is responsible for the successful outreach, scheduling, and care management of assigned patients to meet ACO Value Based. The Patient Navigation Nurse will establish and maintain effective relationships with physicians, clinical staff, patients and caregivers, payers, and community resources. The Patient Navigation Nurse will utilize various computer programs and platforms to gather and analyze data related to the population health program goals and objectives.

Requirements

RN, LPN, CMA licensure required.
Experience with Patient Navigation and ACO preferred.
Demonstrated skills in the areas of communication (verbal and written), conflict resolution, interdisciplinary collaboration, care management, creative problem solving, and critical thinking.
Knowledge of community resources.
Current BLS or obtain within 30 days of hire

Nice To Haves

Experience with Patient Navigation and ACO preferred.

Responsibilities

Utilize motivational interviewing techniques to build trust, clarify patients’ goals, identify reasons for ambivalence and guide patients to take positive steps in managing their health.
Review target patient lists or disease registries to identify high- and emerging-risk patients, evaluating appropriateness for enrollment in Chronic Care Management programs.
Review target patient list and perform Medicare Wellness Visits as assigned.
Review target patient list and perform Chronic Care Management of assigned caseload, including, coordinating medical treatment, completing assessments, developing care plans, monitoring medication compliance, and effectively communicating with patient’s primary care provider and staff as needed to meet patients’ needs.
Complete Transition of Care outreach (TCM phone calls) within established guidelines, scheduling patients for appropriate follow-up with PCP/Specialist accurately and timely. Document outreach efforts and outcome accurately and timely as required for gap closure.
Monitor Medication Adherence gap reports daily. Contact patients to identify potential barriers to medication compliance, provide medication education and interventions to promote adherence to medication regimen.
Facilitate connecting patients with Medication Therapy Management programs with Medicare Advantage programs as required by MA contracts to meet MTM quality measure.
Function as Remote Patient Monitoring coordinator, responsible to receive and resolve RPM escalations from RPM provider during clinic hours. Identify and recommend appropriate CCM/PCM and TOC patients for referral to RPM program as appropriate.
Identify patient barriers to completing recommended preventative screenings, annual wellness visits, and follow up care and assist patients with overcoming barriers.
Function as subject matter expert in community resources to assist patients with identified socio-economic barriers to care. Maintains database of community and payer resources to assist patients.
Maintain accurate records and report to manager, director and others as required.
Contribute to closing gaps in care.
Participate in meetings and collaborate with both internal and external stakeholders to identify and implement effective strategies to meet program goals.
Perform other duties as assigned.