Primary Responsibilities and Specific Duties:
- Acts as advocate for Contracted Entity patient's care needs by identifying and communicating opportunities for care interventions, addressing deficits and gaps in care as indicated.
- Provide follow-up telephone call regarding most recent visits
- Coordinates the care services for Contracted Entity patients with care needs.
- Implements targeted strategies to improve health, functional or quality of life outcomes, such as disease management or pharmacy management, and patient teaching plans.
- Monitors hospitalizations, emergency or urgent visits, institutional facility admissions and re-admissions to identify issues and implement follow up for improved outcomes.
- Routinely monitors patient's status, needs and progress; if progress is static or regressive, assist in identifying a reason and proactively encourage appropriate adjustments to their plan of care with the provider and /or services to promote better outcomes.
- Coordinates and facilitates patient education groups
- Participates in patient care coordination, pre-visit planning, huddles, one-on-one communication, email, patient contact, and documentation of any services accessed and/or health care related concerns/needs that have arisen since last visit.
- Participates in team meetings to communicate and address patient care and operational requirements.
- Discusses self-management goals with patients and assists them in selecting appropriate goals and creating an action plan to achieve them.
- Monitors and documents goals selected and follows up with patients to determine if goals are achievable, in addition to providing assistance to patients when needed in how to achieve their goals.
- For the purpose of reporting to Contracted Entity College with de-identified metrics, the RN Care Navigator tracks client care visits at CHC, including but not limited to stat and urgent orders and referrals; medical care services such as preventive care screenings and assessments and abnormal laboratory results for specific tests.
- Informs supervisor of any problems that may affect quality and the standards of patient services.
- Perform other duties as assigned.
Completion of an accredited Registered Nursing program
- Minimum of two (2) years' experience as a RN in Health Care or Managed Care is preferred.
- Practical experience in a patient educator role or evidence of training in patient education
- Proven ability to function effectively as a member of an interdisciplinary team and proven experience in verbal and written communications and case management service
Active Florida Registered Nursing (RN) license required.
- Knowledge of health implication of chronic diseases and risks.
- Excellent skills in oral and written communications skills.
- High level of initiative and leadership.
- Good advocacy skills.
- Must have proven ability in handling multiple projects and setting priorities, as well as effective time management.
- Bilingual: English/Spanish helpful.
- Able to work flexible hours and other CHC locations as needed.