- The Family Health Centers seeks experience applicant for our care navigator position to serve as a single point of contact for assisting eligible patients to receive comprehensive high quality & cost-effective health care with primary focus on high-risk populations who will benefit from intensive care management services.
- Work to promote a strong relationship between patients and their Primary Care Provider (PCP)/team.
- Track hospitalized patients, by accessing hospital electronic medical records (EMR), and maintaining accurate lists of hospitalized/discharged patients.
- Initiate discharge follow-up protocol for high-risk patients who are discharged from the hospital, using established criteria.
- Begin documenting the relevant basic information about the recent Transition of Care or hospitalization in the office EMR.
- Contact discharged patients within two business days of discharge.
- Using post-discharge script provided, gather information about patient's immediate needs, comprehension of discharge instructions, medications, need for additional services, etc.
- Using a standard assessment form and an established protocol, screen patients to determine needs for intervention or referral to PCP, mid-level provider, Nurse Navigator, pharmacist and/or community agency.
- Communicate need for immediate intervention with appropriate provider.
- Contact community agencies and resources to meet patient's needs (i.e. Request Home Health referral from PCP, transportation, Meals on Wheels, etc.)
- Make/confirm post-discharge follow up appointment with PCP, and with specialists as needed.
- Make additional follow-up telephone calls to patient, as ordered by the provider, to assure patient understands and follows through with the plan of care.
- Review the patient's current/post hospitalization medication and begin to reconcile the medication list, based on medications prescribed at discharge, home medications and practice's list of current medications, highlighting areas of concern for the provider and/or pharmacist.
- Screen and follow up on additional high-risk patients, using processes described above, when referred by PCP, mid-level, Nurse Navigator or pharmacist.
- Provide health education, resource navigation and self- management skill building and support to patients and their families.
- Provide input, based on knowledge of the patient and family, to the development review and evaluation of the patient's plan of care.
- Maintain current and ongoing records of all activities. Primary documentation will be completed in t the HER.
- Maintain confidential accurate records of patients/families.
- Collaborate with patients, colleagues and interdisciplinary team members to achieve desired outcomes.
- Participate in project meetings as directed.
- Participate in project directives for quality improvement as directed.
- Additional duties as assigned by management.
- High level of professionalism, excellent communications skills.
- Strong analytical and organizational skills, detail oriented.
- Ability to work independently and as a team member to facilitate workflow.
- Ability to prioritize work.
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Care Navigator - Asheville, United States - The Family Health Centers
Description
Job Description
Job DescriptionPrimary Responsibilities:
Education and Experience:
· Certified Medical Assistant or LPN
· A minimum of two years of experience as a certified medical assistant or LPN preferred
· Previous experience working with electronic medical records.
Knowledge, Skills and Abilities:
Physical Requirements and Work Conditions:
· Sitting at a desk and performing keyboarding and telephone functions.
· Ability to communicate with a telephone, including hearing and speaking.
· Operating a personal computer is a routine part of the job.
· Clear vision to successfully navigate in the EMR and utilize computer.
· Work environment is fast paced and may be stressful at times.
Compensation: per hour based on experience.
** We are an equal opportunity employer.
