**Become a part of our caring community and help us put health first** **The Role** Working within an interdisciplinary care team, the Care Navigator is responsible for proactively engaging patients identified as high-risk and implementing targeted interventions to address social needs and increase access to care. The Care Navigator will provide guidance and oversight of care coordination efforts to other members of the team, and handle 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 work with patients with behavioral health diagnoses, as well as in navigating local community-based resources and benefit applications. This role is mostly work from home, with the possible occasional meeting to attend in person or to meet patient(s) in the clinic. **Major Duties and Responsibilities** + Conduct Transitions of Care Management for a subset of the patient population, including ER and hospital 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 supports + This field may include but is 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 Team Meetings when indicated + Assess patient’s family system, and conduct family meetings with patient and family when needed + Participate in creation and facilitation of team training content + Conduct group psychoeducation and support groups within the Center + Perform all other duties and responsibilities as required + Participate in and lead 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 **Use your skills to make an impact** **Required Qualifications** + Registered Nurse (RN license) + Minimum of 4 years of experience working in human services and navigating community-based resources **Preferred Qualifications** + Acute care with experience in transition of care, discharge planning, etc + Case Management + Familiarity with state Medicaid guidelines and application processes preferred + Experience working with patients with behavioral health conditions and substance use disorders preferred + Prior experience conducting home visits and knowledge of field safety practices preferred **Skills/Abilities/Competencies** **Required** + 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 **Location:** Must reside in Greater Atlanta or Kansas City metro **Hours:** Must be able to work a 40 hour work week, Monday through Friday 8:00 AM to 5:00 PM, over-time may be requested to meet business needs. **Scheduled Weekly Hours** 40 **Pay Range** The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $71,100 - $97,800 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. **Description of Benefits** Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our 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. **About Us** About CenterWell Senior Primary Care: CenterWell Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. Our unique care model focuses on personalized experiences, taking time to listen, learn and address the factors that impact patient well-being. Our integrated care teams, which include physicians, nurses, behavioral health specialists and more, spend up to 50 percent more time with patients, providing compassionate, personalized care that brings better health outcomes. We go beyond physical health by also addressing other factors that can impact a patient’s well-being. About CenterWell, a Humana company: CenterWell creates experiences that put patients at the center. As the nation’s largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first – for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one. **Equal Opportunity Employer** It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. Centerwell, a wholly owned subsidiary of Humana, complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our full accessibility rights information and language options https://www.partnersinprimarycare.com/accessibility-resources