Patient Support Care Navigator

Brown Medicine•Baltimore, MD

6d•$21 - $35•Onsite

About The Position

SUMMARY: Supports the Nurse Care Management department in caring for rising-risk and high-risk patients and plays a key role in obtaining information about patients with medical and social needs. Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another. In addition to our values, all employees are expected to demonstrate the core Success Factors which tell us how we work together and how we get things done. The core Success Factors include: Instill Trust and Value Differences Patient and Community Focus and Collaborate

Responsibilities

Screens patient census using provided criteria to determine if the patient should be categorized as high risk
Manages the high-risk patient census to assess if intervention from the Nurse Care Manager (NCM) or other disease management/population health program is needed
Assesses patients for basic needs and intervenes when appropriate, referring patients with greater needs to the NCM for intervention
Works closely with the NCM to help patients reach their goals, maintain safety and improve their health
Has awareness and understanding of community and BHMGPC resources/teams to offer patients
Hands off communication to the NCM or other BHMGPC program when necessary
Works with the NCM to develop and update patient care plans and attends care conferences and huddles as needed
Performs telephonic and remote patient outreach to patients, documenting all outreach and interventions in the electronic medical record (EMR)
Facilitates and reinforces patient self-management under the direction of the NCM and encourages patients to keep up to date with labs, PCP and specialist visits and their care plan
Evaluates for patient safety
Ensures documentation is collected from patient specialist visits
Provides resources and disease management education to patients
Comfortable with MOLST and durable power of attorney forms to lightly discuss with patients
Understands durable medical equipment (DME) needs and referrals
Has in-depth understanding of medical insurances and benefits
Assists patients with transportation needs
Performs other job-related duties as assigned