Job Summary

Care Management is an advanced specialty collaborative practice that holds responsibility for providing ongoing care management services for high-risk, complicated patients. The Patient Care Navigator facilitates communication and coordination among all participants of the health care team and patient to ensure that the services provided promote quality, cost-effective outcomes. The Patient Care Navigator provides intensive care management in a process that includes assessment, planning, facilitation, implementation, coordination, monitoring and evaluation of the patient's needs.

Minimum Qualifications

Minimum Education: Associate's Degree or Higher in Nursing
Minimum Years of Experience: None.
Substitutable Education & Experience: None.
Required Certifications/Licensure: Current Registered Nurse;
Required to obtain ACM or CCM certification within 3 years from date of hire.
Required Training: Knowledge of guidelines and regulations relevant to care management and utilization management;
Ability to develop a thorough, comprehensive plan of care, to include options and goals, in collaboration with care team and patient;
Ability to act as an advocate for the patient to assure quality of care and attainment of appropriate goals;
Ability to access and interpret data, utilizing findings in determining plans of care.

Essential Functions

• Performs comprehensive assessment of patients either referred to the program or meeting criteria for triage for the program, to include but not limited to: assessment of patient's physical, functional, social and psychological status; assessment of cultural and linguistic needs; assessment of caregiver resources and available benefits.
• Develops and implements a patient-specific care plan which includes problems, interventions and goals. Communicates with patient's physicians, specialists, community agencies and vendors to ensure coordination of services. Works collaboratively with patient's physicians and members of the interdisciplinary team to assure communication and exchange of input related to patient's specific care needs. Utilizes clinical judgement, independent analysis, evidence-based clinical guidelines, patient preference, and input from interdisciplinary team in making decisions.
• Participates in Grand Rounds Case Conference with other Patient Care Coordinators to assure collaboration, communication and consistency in implementing the program. Fosters sharing of ideas and input. Appropriately identifies cases needing physician, manager, director or medical director review and routes accordingly.

Duties & Responsibilities

• Schedules follow up to assess progress toward goals and identify barriers to meeting goals. Celebrates successes with patient. Prepares and maintains appropriate documentation of patient care and progress within the care plan, following established protocol for documentation of all case interventions. Closes cases according to defined case closure procedure in a timely manner and in accordance with established guidelines.
• Acts as an advocate in the patient's best interest for necessary funding, treatment alternatives, timelines and coordination of care, with frequent evaluations of progress and goals. Continues to identify community and caregiver resources to ensure continuity of care during and after completion of the care management plan.
• Participates in the development of policies, procedures, desktop procedures, assessments and referral templates to facilitate the implementation of and compliance with new care management programs or requirements. Participate in development of processes for oversight and reporting in compliance with new care management programs and requirements.
• Performs all other duties as assigned.