PURPOSE OF THIS POSITION

The Care Navigator nurse provides intensive physician-office-based case management support for a case load of patients in the Care Navigation program sponsored by BVHS and Hancock Medical Group, and other managed care programs/alternate payment models as developed and adopted. The Care Navigator’s role is to aid patients who have complex health needs in improving their health or managing their chronic condition, through individual counseling sessions, telephonic or electronic contacts, office visits with physicians, and some home visits.  By providing case management for patients and involving the patient’s family, a Care Navigator focuses on patient education and compliance with the care plan, including medication adherence. The Care Navigator works closely with Medical Home/primary care practices and specialty practices for development of the care plan and case management, and is embedded in the physician offices. The Care Navigator works closely with hospitals, home care and other providers to coordinate transitions across the care continuum and arrange access to community resources needed by patients. The Care Navigator uses computer systems and tools for population management activities, to identify potential patients for case management, for access to patient information and for documentation of Care Navigation activities. The Care Navigator plays a key role in developing and implementing the programs.

JOB DUTIES/RESPONSIBILITIES

Duty 1: Using patient centric team based approach, acts as liaison to coordinate patient care and facilitate patient care pathway, among payers, physicians, physician offices, nursing, surgical department, therapy department, pharmacy, case managers, discharge planning, post-acute care, and other hospital departments as needed.

Duty 2: Establishes regular communication and works on site in physician offices to accept referrals of patients to the Care Navigator program and to case manage the patient load. Serves as a clinical resource/consultant to physician practices to optimize communication and effective utilization of health care resources.

Duty 3: Identifies and prioritizes patient caseload using designated patient identification process, daily admission and ER visit reports, the Medical Home registry, medication compliance profiles, physician and office staff referral, patient self-referral, and other means approved by the Medical Management Committee and BVHS.

Duty 4: Coordinates care and addresses individual needs of patients who are assigned to caseload through the course of the designated episode, including direct patient support for the collection of functional outcomes and reporting.

Duty 5: Utilizes nursing processes to assess and plan strategies for patient care with emphasis upon appropriate resource utilization, appropriate levels of care, quality and patient and family education. Develops and implements plans of care which address the specific diagnosis, age, gender, psycho-social and emotional needs of each patient, and which are culturally sensitive.

Duty 6: Establishes and maintains communication/collaboration with the interdisciplinary team across the continuum of care (inpatient case management, home care, SNF care) and with the patient's primary and specialty providers regarding patient condition, orders, plan of care, anticipated needs, and progress. 

Duty 7:  Evaluates patient access to needed services and coordinates access to the care continuum and community resources. Maintains active communication and collaboration with BVHS entities and community agencies and resources to assist patients and families to gain access to these services. Appropriately refers patients with physician approval to appropriate resources for education, services, and resolution of care issues of the patient.

Duty 8: Counsels directly and often in person with patients and families to promote education, care plan compliance and improved health of patient. Communicates with patients in person, via telephone, text, letter and email. Attends physician office visits to primary care physicians or specialists when appropriate for the patient’s care plan. Conducts home visits to patients as appropriate.

Duty 9: Manages, documents and reports on caseload including documenting plans and contact records, tracking and evaluating case management activities and outcomes on an individual and aggregate basis. Outcomes include quality, compliance with care guidelines, costs, resources used, and patient and physician satisfaction. Uses electronic documentation system for patient documentation and care management, concurrently (not delayed or “bulk” documentation).

Duty 10: Serves as clinical resource to EDOC Medical Management Committee and BPCI-A Oversight Committee in the development of evidenced based guidelines and in the development and evaluation of data and reports. Participates in various committees and prepares reports to contribute information regarding utilization of services and quality of healthcare for the purpose of improving patient care and outcomes.

Duty 11: Works with data analyst to collect, manage and analyze data specific to patient and provider population. Helps analyze aggregate data for trends and outcomes and to measure performance of program and providers on goals and objectives. Utilizes data findings and provider and patient feedback to evaluate program strengths and weaknesses and to identify and implement areas for improvement.

Duty 12: Provides coverage for other care navigators as required. Manages on-call assignments as required effectively including timely physician and patient communication, record keeping, and keeping management informed of any unusual or special incident occurrences.

Duty 13: Displays Service Excellence as evidenced by practicing the mission, vision, and values of the organization to promote patient satisfaction.

Duty 14: Continually evaluates the care navigation program for opportunities for improvement and works collaboratively to implement changes for improvement.

REQUIRED QUALIFICATIONS

Current Ohio license (RN or BSN) and excellent clinical skills 2+ years of experience in chronic disease management, care navigation or case management 5+ years of experience in critical care, cardiopulmonary nursing and/or emergency nursing Demonstrated track record of being self-directed and motivated. Must have demonstrated ability to assess clinical information and assess implications of treatment. Must be willing to work a flexible work schedule to accommodate the population being served, i.e., may require one evening per week and one – two Saturday mornings per month. A valid driver's license is required (if you do not have a valid Ohio driver’s license you must obtain one within one year of your residency in the state) and you must also meet BVHS's company fleet policy requirements Must have strong computer skills use including basic Excel and Word skills, and willingness to expand those skills Requires coverage of two to five separate physician practice locations on a weekly basis. May require driving between two – three sites in one day (up to 20-30 minutes driving distance) or working at a different location each day of the week. Requires some visits to patient homes which may require climbing of stairs. Requires daily carrying of laptop computer and files between physician office locations. Within each physician office, requires walking between physician exam rooms and being on your feet for significant periods of the day. Must be an excellent patient educator. Must be able to effectively and credibly deliver to patients, in a one on one or group setting, with or without a physician being present, information about the importance of complying with chronic condition self-management approaches and medication adherence. Positive service-oriented interpersonal and communication skills required, including ability to deal directly, assertively and appropriately with matters of a sensitive or controversial nature. Possesses the ability develop and maintain collaborative relationships, and to work as a team member in an interdisciplinary environment for the provision of quality care, and to build consensus among diverse groups. Possesses knowledge and skill in coordinating and managing patient care across the continuum. Proven ability to set priorities and to achieve program goals. Excellent critical thinking and analytical skills. Ability to use independent judgment and discretion about matters of significance. Exercise of judgment and discretion in matters of confidentiality, including in relation to physician performance analysis. Individual must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patient served on his/her assigned primary care office. The individual must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient status.  Must be able to interpret the appropriate information needed to identify each patient’s requirements relative to their age-specific needs and to provide the care needed as described in the area’s policies and procedures

PREFERRED QUALIFICATIONS

BSN or Master’s degree preferred Physician office nursing, health plan or home care nursing experience preferred. Experience as a clinical program coordinator or comparable program management experience Smoking cessation certification

PHYSICAL DEMANDS

This position requires a full range of body motion with intermittent walking, lifting, bending, climbing, squatting, kneeling, twisting, sitting, and standing. The associate will be required to walk up to 2 hours a day, sit for 4 hours a day, and stand for 2 hours a day. The individual must be able to lift 30 pounds and reach work above the shoulders. The individual must have good eye/hand coordination and fine finger dexterity, including the ability to document legibly. This associate must have excellent verbal communication skills to perform daily tasks. The associate must have corrected vision and hearing in the normal range.

*This position is classified “at risk” for possible occupational exposure to blood borne pathogens (HBV, HIV, etc.)

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