JOB TYPE: / Care Navigator
HOME COMPANY: / The Villages Health System, LLC.
HOME BUSINESS UNIT: / The Villages Health
REPORTS TO: / Clinical Manager
FLSA STATUS: / Non-Exempt
PRE-REQUISITE: / none
UPDATED/REVIEWED: / 9/6/2013. 1/25/2016
FILE CODE: / 850.0483
SCOPE OF RESPONSIBILITIES

A nonexempt position responsible for nursing care under the supervision of Physicians and Clinical Manager.

Care Navigation is a collaborative process which assesses,plans, implements, coordinates, monitors and evaluates the options and services required to meet an individual’s health needs, using communication and available resources to promote quality, cost effective outcomes.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. While this is intended to be an accurate reflection of the current job, management reserves the right to revise the job or to require that other or different functions be performed when circumstances change or exigencies require (this includes but is not limited to emergencies, changes in personnel, workload, rush jobs, or technological developments).
  1. Identify patients appropriate for Care Navigation through referrals and collaboration with PCP and Clinical Teams.
  1. Establishes a patient specific plan of care based on collaboration with patient/family, providers and payers that identify appropriate levels of care.
  1. Uses customer service principles and techniques to deal with patients calmly and pleasantly.
  1. Obtains, verifies, and records health history of patients. Gathers pertinent health data while reviewing patient's previous records. Populates information fields in the EMR.
  1. Documents all assessments, plans of care and Care Navigation activities in a timely manner.
  1. Ensures effective communication and collaboration with multidisciplinary patient care teams.
  1. Interacts in a collegial and collaborative fashion with outside clinical staff such as specialists, social workers, and other clinical and nonclinical support staff.
  1. Emphasizes continuity of care and seamless integration during transitions of care to avoid duplication or gaps in plan of care.
  1. Monitors patient progress while in the acute care and post-acute care settings. Assist with facilitation of discharge process/transition of care to the appropriate level of care.
  1. Continue to monitor patient’s progress post discharge in an effort to prevent re-admission to acute care and to maximize outcomes.
  1. Identify opportunities for health promotion and illness prevention.
  1. Maintains a comprehensive working knowledge of community resources, payer requirements and network services.
  1. Acts as patient advocate.
  1. Provides patient education, monitor of health needs and coordination of community resources. Services may be provided in a variety of setting including clinic, home visits, hospitals or skilled nursing facilities.

SENTIAL DUTIEES include the following. Other duties may be assigned.

EDUCATIONAL REQUIREMENTS
  • Current, unrestricted RN license in the state of Florida.
  • 2+ years experience in a hospital or acute care setting with direct patient care

EXPERIENCE
  • Case Management experience
  • RESPONSIBILITIES

KNOWLEDGE
  • Knowledge of medical terminology, anatomy, physiology, and pathophysiology.
  • Familiarity with health care systems, electronic medical records, regulations, policies, and functions.
  • Understanding of documentation standards.
  • Knowledge of equipment, supplies, and material needed for medical treatment.
  • Understanding of basic laboratory, procedures including preparation and screening. .
  • Knowledge of infectious disease management and control and safety standards.

SKILLS
  1. Strong coaching ability.
  2. Excellent clinical skills and judgment.
  3. Excellent written and verbal communication skills, with the ability to build relationships
  4. Excellent organizational skills
  5. Strong ability to work autonomously and be self-directed
  6. Strong critical thinking skills.
  7. Skill in initiating appropriate emergency procedures.
  8. Skill in handling a number of tasks simultaneously.
  9. Skills in diplomacy and tact withall interpersonal interactions.

Abilities:

  1. Ability to communicate calmly and clearly with patients.
  2. Ability to use manual dexterity to perform medical treatments.
  3. Ability to establish and maintain effective working relationships with coworkers and diverse patient populations.
  4. Ability to perform mathematical calculations for drug dosages.
  5. Ability to work with computer and effectively use electronic medical records (EMR).
  6. Ability to work under pressure.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Occasional exposure to communicable diseases and biohazards. Daily standing, squatting, walking, bending. and maneuvering. May require lifting up to 50 pounds to transfer and or assist a patient in standing on the scale or sitting on the exam table. Stress can be triggered by workload and difficult patients. .

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

Medical exam and treatment rooms and medical offices. Environment setting (lighting, temperature, air quality, acoustics) controlled.

ACCESS TO PROTECTED HEALTH INFORMATION (PHI)

WORK ENVIRONMENT

This position requires FULL access to Protected Health Information (PHI), and will adhere to HIPAA regulations regarding PHI.

Employee and supervisor have reviewed the above job description and determined that it accurately reflects the position. Employee acknowledges and agrees that he/she is qualified to perform the essential functions of the position [with] or [without] accommodation.

______

Employee Name

______

Employee SignatureDate

1