RN Primary Care Navigator | Polson Primary Care Clinic

Logan Health Medical Center•Polson, MT

1d•Onsite

About The Position

Polson Primary Care is seeking a resourceful and compassionate RN to join their team as a Primary Care Navigator. This position is vital for Transitional Care Management, Emergency Department follow-up, day-to-day coordination and clinic support, as well as Chronic Care Management services. The RN Primary Care Navigator will help patients, ranging from pediatrics to the elderly, connect with essential healthcare services. The role focuses on chronic disease management, patient education, care coordination, emergency department follow-up, and clinic support. The individual will serve as a crucial liaison between patients, families, and healthcare teams, ensuring smooth transitions and continuity of care.

Requirements

Current Montana RN license or a multi state compact license with authorization to practice nursing within the state of Montana; required.
RQI Provider (BLS) within 7 days of hire/transfer or before independent patient care, whichever comes first.
Possess and maintain computer skills to include working knowledge of Word, Outlook, Excel, PowerPoint, Access and ability to learn other software as needed.
Must function with a high degree of autonomy, communication and interpersonal skill.
Must understand the health care continuum and have the ability to solve complex problems.
Demonstrated ability to work collaboratively with multidisciplinary medical home care teams.
Knowledge of professional practice standards, regulatory requirements, and systems operations required.
Excellent organizational skills, detail-oriented, a self-starter, possess critical thinking skills and be able to set priorities and function as part of a team as well as independently.
Commitment to working in a team environment and maintaining confidentiality as needed.
Excellent verbal and written communication skills including the ability to communicate effectively with various audiences.
Excellent interpersonal skills with the ability to manage sensitive and confidential situations with tact, professionalism, and diplomacy.

Nice To Haves

Bachelor’s Degree in Nursing preferred.
Knowledge of electronic health records preferred.
Nursing experience in a variety of care settings (Outpatient Clinic, SNF, Home Health, and Acute Care) preferred.
Knowledge of Value-based payment models and the Medical Home care model preferred.
Ability to evaluate clinical outcomes across a variety of primary care settings and familiarity with diabetes and lipid management, including dietary assessment preferred.
Experienced RN with history of managing chronic conditions is highly preferred.

Responsibilities

Enroll patients in the CCM Program and educate them on program benefits.
Outreach to patients that may need care navigation services.
Provide patient education on chronic disease management, medication adherence, and treatment plans.
Coordinate care across multiple settings such as primary care, specialty services, inpatient and outpatient settings.
Facilitate timely scheduling of appointments, referrals, diagnostic testing, and procedures.
Assist patients in accessing resources for housing, care assistance, and placement services.
Engage with primary care and specialty providers to facilitate communication and optimize patient outcomes.
Track patient progress and provide follow up as needed to ensure effective care management.
Assesses patient needs upon initial encounter and periodically throughout navigation.
Matches unmet needs with appropriate services, referrals and support services, such as dietitians, providers, social work, pharmacy, and financial services.
Acts as a liaison between the patients, families, caregivers and the providers to optimize patient outcomes.
Identifies high risk patients who would benefit from chronic care management and works collaboratively with the primary care provider, patient, and family to develop an individualized patient-centered plan of care.
Participates in coordination of the plan of care with the multidisciplinary team, promoting timely follow-up on treatment.
Utilizes appropriate assessment tools (e.g., PHQ2/9, mini cog, pain scale, etc.) to promote a consistent, holistic plan of care.
Provides psychosocial support to and facilitates appropriate referrals for patients, families, and caregivers, especially during periods of high emotional stress and anxiety.
Provides and reinforces education to patients, families, and caregivers about chronic disease process, discharge teaching/instructions, new diagnosis, and medications.
Builds therapeutic and trusting relationships with patients, families, and caregivers through effective communication and listening skills.
Utilizes motivational interviewing techniques to assist patients in meeting goals and managing chronic disease.
Facilitates communication among members of the multidisciplinary primary care team to prevent fragmented or delayed care that could adversely affect patient outcomes.
Supports a smooth transition of care for patients from one level of care to another.
Provides acute care, skilled nursing facility, and emergency department (ED) follow up.
Participates in the tracking of metrics and patient outcomes, in collaboration with administration, to document and evaluate outcomes of the navigation program.
Focuses on prevention measures consistent with established guidelines and care process models and works toward continuously improving quality metrics and closing care gaps.
Collaborates with the care navigation team to develop and improve workflows and protocols for primary care that ensure hospital, ED, and community resource follow-up.
Exhibits effective communication with peers, members of the multidisciplinary healthcare team, and community organizations and resources.
Works collaboratively with fellow members of the Care Navigation team, providers, and integrated multi-disciplinary team members.
Maintains regular and consistent attendance as scheduled by department leadership.