The Nurse Navigator will collaborate with a multi-disciplinary team including PCP, BH Care Managers, Mental Health professional and counselors to implement measurement-guided and evidence-based practice guidelines to promote and support patient outcomes in community-based organizations and rural health clinic settings.
The Nurse Navigator provide clinical guidance, education, and support to patients in need of preventive and chronic care services; specifically assisting those patients with multiple co-morbidities and complex health status in order to improve health outcomes. The Nurse Navigator will perform outreach to patients in need of clinical assessment and intervention. The Nurse Navigator will assist with the development of telephone scripting for patient education. This position will also assist in the development and gathering of clinical metrics and will work with other members of the Clinical Quality team to help improve HEDIS, STARS, UDS scores for all clients of Target Health.
Minimum Requirements
• Licensed LPN or RN
• Two years clinical experience
• Experience with HEDIS/Quality/QARR/STARS/UDS
Preferred Qualifications
• Licensed LPN/RN preferred with two years minimum clinical experience and/or two years minimum experience in an Outreach setting, Managed Care, Case Management, Ambulatory clinic setting, or related field
• Bilingual preferred, (English/Spanish)
• Bachelor Arts /Bachelor Science
Knowledge, Skills, and Abilities Requirements
• Strong interpersonal and assessment skills, especially the ability to relate well with seniors, patients, and families
• Excellent verbal and written communication skills required
• Knowledge and experience with the current community health practices for the frail adult population and cognitively impaired seniors
• Experience managing patient information in a shared network environment using paperless database modules and archival systems
• Proficient with simultaneously navigating the Internet and multi-tasking with multiple electronic documentation systems
• Experience and knowledge of the relevant insurance types and offerings
• Previous health education or case management experience
• Ability to work independently with minimal supervision in achievement of departmental goals for engagement and productivity
• Intermediate proficiency with Microsoft Outlook, Word and Excel (including ability to edit, search, sort and filter data)
Job Duties:
• Assess, plan and implement individual patient care coordination
• Conduct SDOH and Behavioral Health Screenings to identify and initiate referrals to social service and mental health programs including financial, psychosocial, and community-based supportive services.
• Responds to questions raised during patient outreach calls and troubleshoots/intervenes as needed.
• Conducts telephonic outreach to certain patient populations with significant chronic conditions or behavioral health issues and/or co-morbidities to help improve access to care and the overall health status of the population.
• Advocates for patients and families as needed to ensure the patient’s needs and choices are fully represented and supported by the healthcare team.
• Responds to questions raised during patient outreach calls and troubleshoots/intervenes as needed.
• Collaborates with providers, community-based services, and internal departments to coordinate care and assist patients with adequate access to care and services.
• Assists with the development of call scripts to address quality measures/ and patient health outcomes to drive success of outreach.
• Documents all encounters with providers, patients, and vendors in the identified system in accordance with internal and established documentation procedures and follows up as needed.
• Participates in Quality Management Program by identifying improvement opportunities related to HEDIS/QARR/STARS/UDS, including performance and thorough documentation of clinical services.
• Assists in supplying metric data for quality studies and HEDIS planning.
• Contributes to departmental and corporate goals through ongoing execution of care gap closures and associated member health outcomes improvement.
• Communicates with all stakeholders to ensure quality Integrated Community Case Management (ICCM) and care collaboration and services are being provided expeditiously to all partners.
• Conduct visits with patients in home or other settings, including community centers, provider offices, etc.
• Performs outreach to patients recently seen in the ER or who were recently admitted to a hospital to assist with coordinating access to care and services based on individual needs.
• Meets productivity standards as =defined by organization
• Entering data into and maintaining accurate patient registry.
Reports To
• Nurses and Target Health Leadership Team
