The Care Navigator is responsible for providing comprehensive, compassionate, and appropriate care navigation services for the patients of the Equitas Health Medical Centers. Care navigators have the responsibility of consulting with patients to determine their individual needs, partnering with Equitas Health providers to develop care plans, coordinating patient care and community resources, and working with the Equitas Health Clinical Care Team to evaluate and implement the appropriate interventions. The Equitas Health Care Navigator will play an essential role in ensuring Equitas Health meets its goal of delivering the Quadruple AIM. The role of the Care Navigator will be guided by the NCQA Patient Centered Medical Home framework, while meeting the unique needs of Equitas Health patients and providers.
ESSENTIAL JOB FUNCTIONS:
Essential functions of the job include, but are not limited to, traveling, driving, having reliable transportation to transport clients and meet clients, utilizing a computer for typing and conducting research, attending meetings, conducting assessments, and counseling.
MAJOR AREAS OF RESPONSIBILITY:
Promotes and reinforces patient centered medical home concepts with patients, families, and the Equitas Health care team.
Participate in the development and implementation of an evidence based, standard screening tool for identifying patient’s social determinants of health. The care navigators will utilize this tool to determine factors that contribute to a patient’s overall health outcomes, and develop the appropriate intervention/care plan for the patient.
Assist patients in accessing Equitas Health resources and navigating external healthcare and community resources such as housing, respite, nutritional assistance, palliative care, chore assistance, transformation and social functions; taking into consideration reading level, health literacy, culture, and language requirements. Assess barriers to care and engage patients and families in creating potential solutions to overcoming these barriers through the use of motivational interviewing and shared decisions making.
Refer to community workforce programs and provide supportive services to patients that address the unique barriers to employment individuals may face in returning to work, understanding benefits eligibility, confidentiality and health management in the workplace.
Collaborates with providers, client services, and care team to develop short and long term strategies in the development of expected patient outcomes as they impact the patient’s physical health, mental health, and ability to function within their day to day environment; collects data through patient tracking to meet patient’s needs.
Works collaboratively with providers and care team to ensure the delivery of quality of care to patient to ensure the best patient outcome.
Collects data through patient tracking in order to facilitate patient outcomes data collection and analysis.
Participates in transitional care management outreach to patients post hospital admission to determine needs and works with scheduling and clinical staff to ensure patients are seen in the clinic after a hospital admission or observation.
Provides education, utilizing motivational interviewing and shared decision making, to patients who are inappropriately utilizing the emergency department. Collaborates with providers and care team to determine appropriate next steps or required interventions for non-compliant patients.
Provide assistance with completing and submitting all necessary documentation related to patient’s care, including documents related to Ryan White benefit, health insurance, medical procedures, and internal and external referral services.
Serves as a link between Equitas Health Medical Center and Client Services, ensuring patient’s needs are being met with timeliness and efficiency.
Maintain confidentiality of patients by adhering to Equitas Health Confidentiality Policy and Procedure, HIPAA, and other established professional standards and guidelines.
Care Navigators are responsible to maintain documentation through Equitas Health, ODH, and other software systems. All documentation will be recorded and complete within one business days of provided service.
Effective written and verbal communication skills. Ensure that action items and updates are provided to Supervisor proactively. Capture feedback from patients, families, Equitas Health care team, and community partners and communicate the information to the appropriate persons.
Returns patient, provider, and other stakeholder correspondence within one business days.
Responsible for accurate and timely completion of documentation in order to provide accurate data and reports to Equitas Health and its Board, as well as federal, state, and local governments.
Attend trainings, as assigned, to improve case management skills related to written and verbal skills, putting theory into practice, and accurate documentation across multiple systems.
Care Navigators will participate in Motivational Interviewing trainings and Learning Groups. As appropriate, Supervisors will schedule shadowing and review recorded visits between staff and patients in order to evaluate Motivational Interviewing skills.
Participate in Equitas Health Committees and Performance Improvement Teams as appropriate and as assigned by supervisor.
Demonstrates unconditional positive regard to patients; Conducts all aspects of job responsibilities with a focus on exceptional customer service.
Demonstrates continuous growth and development of Cultural Competency exhibiting an understanding, awareness, and respect for diversity.
Attend monthly, quarterly, and as needed meetings in-person at multiple agency sites and community partner locations.
Utilize email, Skype, phone, and other telecommunication options to participate in meetings across sites.
Other duties as assigned related to this position by supervisor.
KNOWLEDGE, SKILLS, ABILITIES AND OTHER QUALIFICATIONS:
Education Requirements: LPN, RN, Bachelor’s Degree in Science, Social Work or related field.
Licensure Requirements: RN. Preferred LSW
Must have sensitivity to, interest in and competence in cultural differences, HIV/AIDS, minority health, sexual practices, and a demonstrated competence in working with persons of color, and gay/lesbian/bisexual/transgender community.
Medical and Community-based care navigation training experience desired.
Understanding of NCQA Patient Centered Medical Home, Comprehensive Primary Care Initiative, Accountable Care Organization, or other value based care delivery model preferred.
Experience working in a multidisciplinary team required
Proficiency in all Microsoft Office applications and other computer applications required.
Reliable transportation, driver’s license and proof of auto insurance required.
Background and reference checks will be conducted. Hours may vary, including working some evenings and weekends based on workload. Individuals are not considered applicants until they have been asked to visit for an interview and at that time complete an application for employment. Completing the application does not guarantee employment. In accordance with Equitas Health’s Drug-Free Workplace Policy, pre-employment drug testing will be administered. EOE/AA