Description:
Functions as a liaison that collaboratively works with patients, physicians, and referral sources in the community to manage and improve the health conditions of each patient by educating the patient/families and coordinating additional services needed. The Care Navigator works under the guidance of the RN Care Coordinator and Quality Leadership to provide collaborative care management services.
Responsibilities:
- Responsible for carrying out key functions related to patient outreach, quality reporting, and performance measurement and acting as a key liaison between physician and patient.
- Performs outreach functions, as necessary, to patients that have been identified as having chronic conditions that meet eligibility requirements for their program.
- Assesses, identifies, and prioritizes individual needs and builds rapport and trust with patients.
- Reviews and assesses the member’s available data, including clinical history, outpatient/inpatient treatments, emergency room visits, medications, chart reviews, or other information, to assist in monitoring and facilitation of adherence to prescribed care plans.
- Collaborates with the patient and provider regarding opportunities for optimizing care and closing gaps.
- Facilitates patient understanding of the physician’s treatment plan, including but not limited to, prescriptions, prescription refills, medical supplies, referrals, authorization of services, and when to seek care.
- Performs assessment of the patient and/or family to further assess social, emotional, functional, and physical health status.
- Promotes education by supplying informational materials and directing the patient to the appropriate agencies and facilities in the community for care.
- Responsible for understanding, assisting, educating, and facilitating the overall plan of care of patients with chronic conditions.
- Responsible for understanding, assisting, educating, and facilitating the maintenance and promotion of preventative care of a chronic patient including promotion of preventative screenings, lifestyle coaching, and on-going follow up care.
- Serves as a liaison between practice and insurance payors concerning the care and treatment options of certain patients with chronic health conditions.
- Provides education to providers, office managers, and other clinic staff relating to quality initiatives and clinical documentation improvement.
- Maintains continuity of care among care coordination team members by documenting and communicating actions, opportunities, and continuing needs.
- Assures evidence-based practice guidelines are incorporated in to patient’s plan of care.
- Assists in the coordination of transitions in care for designated patient populations.
- Monitors care processes to provide cost-effective implementation and evaluation of utilization management and patient care initiatives.
- Maintains effective communication with payer care coordination team to collaborate on patient care initiatives and care management strategies.
- Demonstrates knowledge of payer contracts including required quality metrics and available payer resources to assist in care coordination efforts.
- Demonstrates knowledge of HEDIS, HCCs, and Medicare Risk Adjustment and their impact on pay-per-performance contracts.
- Follows policies, procedures, and safety standards. Completes required education assignments annually. Works toward achieving goals and objectives, and participates in quality improvement initiatives as requested.
- Performs other duties as assigned.
Qualifications:
Minimum Education:
None specified; however, must be sufficient to meet the standards for achievement of the below indicated license and/or certification as required by the issuing authority.
Minimum Experience:
Three to five (3-5) years of experience in a clinical setting, case management, or utilization review experience preferred. Must be computer literate with basic knowledge of Microsoft Office programs. Ability to build rapport and engage patients in effective dialogue related to their treatment plan. Ability to quickly identify and prioritize patient’s needs and provide structured and focused support and interventions. Exceptional level of critical thinking, analytical, and creative problem solving skills. Exceptional level of independence, organization, and interpersonal skills.