RN/LPN/CMA - PATIENT CARE NAVIGATOR

Horizon Health•Paris, IL

10d•$16 - $38

About The Position

Horizon Health is a Critical Access, Rural Health Facility with 25 inpatient beds in Paris, Illinois, and outpatient Family Practice and Specialty Clinic settings in Paris and surrounding cities. The Patient Navigation Nurse is responsible for outreach, scheduling, and care management for assigned patients to support ACO value-based goals. The role builds and maintains effective relationships with physicians, clinical staff, patients and caregivers, payers, and community resources, and uses computer programs and platforms to gather and analyze population health data. The position supports patients through chronic care management, Medicare Wellness Visits, transitions of care, medication adherence, remote patient monitoring, preventive screenings, and follow-up care. The navigator identifies patient needs and barriers, coordinates appropriate services, documents outreach and care activities, and collaborates with internal and external stakeholders to advance program goals and close gaps in care. Other duties may be assigned in support of hospital goals and objectives.

Requirements

RN, LPN, or CMA licensure.
Demonstrated verbal and written communication, conflict resolution, interdisciplinary collaboration, care management, 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 and ACO.

Responsibilities

Use motivational interviewing to build trust, clarify patient goals, identify ambivalence, and guide patients toward positive health-management steps.
Review patient lists and disease registries to identify high- and emerging-risk patients and assess their suitability for Chronic Care Management programs.
Review target patient lists and 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 within established guidelines and schedule timely, appropriate follow-up with primary care providers or specialists.
Document outreach efforts and outcomes accurately and promptly for gap closure.
Monitor medication adherence gap reports daily, contact patients about barriers, and provide medication education and interventions to support adherence.
Connect patients with Medication Therapy Management programs through Medicare Advantage programs as required by contracts.
Coordinate Remote Patient Monitoring by receiving and resolving provider escalations during clinic hours and recommending appropriate patients for referral.
Identify barriers to preventive screenings, annual wellness visits, and follow-up care, and help patients overcome them.
Use knowledge of community resources to address socio-economic 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 identify and implement strategies to meet program goals.
Perform other duties as assigned.