RN Care Navigator

CenterWell Home Health • Belle Glade, FL

28d • Hybrid

About The Position

Become a part of our caring community and help us put health first Care Navigator - Registered Nurse Job Summary Working within an interdisciplinary care integration team (CIT), the Care Navigator - Registered Nurse is responsible for proactively engaging patients and implementing targeted interventions to address whole person health and increased access to care. The Care Navigator - Registered Nurse will provide guidance and oversight of care coordination efforts to other members of the team, and manage clinical escalations as indicated. This role requires an understanding of how socio-economic stressors can impact ability to engage in healthcare and subsequent health outcomes. Experience will ideally include prior care or case management work with transitions of care and high-risk patient management programs in partnership with PCP care team members including community health workers, pharmacists, and behavioral health specialists.

Requirements

• Unrestricted Registered Nurse (RN license) in the state of Florida
• Minimum of 4 years of experience working in human services and navigating community-based resources
• Acute care and/or case/care management experience
• Ability to work M-F 8-5
• Ability to work true hybrid position - travel to members' homes/clinics/facilities
• Driver's License, Reliable Transportation, Insurance This role is part of Humana's Driver safety program and therefore requires an individual to have: a valid state driver's license, carry insurance in accordance with the state minimum required limits, or $25,000/$25,000/10,000 whichever is higher and a reliable vehicle.
• To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership. Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Nice To Haves

• Bilingual in English and Spanish or Creole with the ability to speak, read and write in both languages without limitations or assistance
• Prior value-based care experience and working with complex Senior populations
• Experience working effectively within interdisciplinary teams
• Advanced clinical acumen
• Ability to multi-task in a fast-paced work environment
• Flexibility to fluidly transition and adjust in an evolving role
• Excellent organizational skills
• Advanced oral and written communication skills
• Strong interpersonal and relationship building skills
• Compassion and desire to advocate for patient needs
• Critical thinking and problem-solving capabilities

Responsibilities

• Conduct Transitions of Care Management for a subset of the patient population, including hospital, obs, and post-acute care follow ups
• Provide triage guidance and supportive consultation to other team members, handling escalated complex cases
• Develop care plans leveraging 5Ms Geriatric best practice framework
• Develop a wholistic view of patient needs related to Social Determinants of Health
• Identify existing barriers to engagement with necessary resources and supports
• Provide education around maintenance of chronic health conditions, as well as available options for behavioral care and social support
• Serve as liaison between the patient and the direct care providers, assisting in navigating both internal and external systems
• Initiate care planning and subsequent action steps for high-risk members, coordinating with interdisciplinary team
• Supporting patients' self-determination, motivate patients to meet the health goals they have identified
• Refer patient to necessary services and support across the interdisciplinary team This may include and not limited to: assistance with transportation, food insecurity, navigation of and application for benefits including, Medicaid, HCBS, working to reduce costs associated with prescription medications, organizing schedules of follow up appointments, alleviating social isolation
• Lead Interdisciplinary CIT Team Meetings when indicated
• Assess patient's family and caregiver system, and conduct family meetings with patient and family when needed
• Participate in creation and facilitation of team training content
• Participate in and lead CIT interdisciplinary review of and coordination around complex patients
• Maintain patient confidentiality in accordance with HIPAA
• Document patient encounters in medical record system in a timely manner
• Follow general policies related to fire safety, infection control and attendance
• Perform all other duties and responsibilities as required

Benefits

• Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees