The Health Navigator works in collaboration with the primary care provider and all members of the health care team. Accepts referrals and manages assigned caseload. Develops care initiatives to assess and coordinate chronic disease care management for their patient population in manner that is medically appropriate and cost effective. Responsible and accountable for direct and indirect patient care for designated patient populations. Assesses healthcare needs and identifies community resources. Serves as patient advocate and assists in identification and improvement of service delivery. This position requires expertise in the nursing process, using critical thinking skills to plan and coordinate care. The nurse also serves as a clinical resource to other clinical staff.
- Collaborate in overseeing the practice’s care coordination initiatives.
- Identify improvement opportunities and improved efficiency by targeting goals and performance measures
- Identify and implement processes to promote patient centered care and patient engagement.
- Assist with and facilitate the transition of care from inpatient settings such as hospital, rehabilitation facilities and skilled nursing facilities to home.
- Develop a comprehensive, collaborative care plan, based on provider treatment plan and patient/family goals for recently discharged patients and promote adherence to physician/provider recommendations and instructions.
- High risk and chronic disease management - provide nursing care via face-to-face, telephonic and/or electronic communication.
- Provide individual patient/family education and self-management support that is appropriate based on language, cognitive abilities, literacy level, learning style, cultural norms, patient preference, readiness for change and resources available.
- Provide education to patients regarding health conditions.
- Identify and implement cost –effective problem solving, process improvement, risk assessment and the reduction of waste.
- Collaborate in goal planning and care management.
- Communicate changes in patient’s status appropriately with the care team.
- Perform an after visit summary review with navigator patients when appropriate.
- Identify barriers when treatment goals are not met and/or treatment plan is not being followed.
- Identify patients who are overdue for visits, labs and referrals, contact patients and arrange for follow-up services.
- Assist the patient in improved healthcare access and promote patient knowledge of health and behavior change.
- Utilize appropriate protocols and standing orders in delivering patient care.
- Track and trend data to improve care delivery; report quality measures.
- Serve as a clinical resource and community referral resource within the practice.
- Assist providers with shared medical appointments and group visits.
- Participate in regular team meetings, huddles, staff meetings and quality improvement projects to improve patient care.
- Consult with the medical staff, nursing staff and ancillary department staff to eliminate barriers to the efficient delivery of care. Identify service delivery problems and potential for effective patient management intervention.
- Follow-up with assigned patients on all labs, tests and consults to ensure work is done.
- Document all communication with patient in electronic medical record.
- Perform all other duties as assigned.
- Ability to work independently and exercise clinical judgment in interactions with providers, payers, patients and their families.
- Strong organizational and time management skills, as evidenced by a capacity to prioritize multiple tasks and role components.
- Strong analytical and data management skills.
- Aware of scope of practice boundaries, comfortable seeking direction and assistance from appropriate resources.
- Ability to communicate effectively verbally and in writing.
- Proficient ability to use a computer and electronic medical record.
- Comply with all HIPAA regulations - maintain patient, team member and employer confidentiality.
- Customer Service Oriented – friendly, cheerful, helpful and cognizant of patient needs.
- Ability to adapt easily to changing conditions and work responsibilities.
- Ability to organize and direct a project to completion.
- Ability to work as part of a team and collaborate with co-workers.
- Ability to complete assigned tasks under stressful situations.