PURPOSE OF THIS POSITION The Care Navigator nurse provides intensive physician-office-based case management support for a case load of patients in the Care Navigation program sponsored by BVHS and Hancock Medical Group, and other managed care programs/alternate payment models as developed and adopted. The Care Navigator's role is to aid patients who have complex health needs in improving their health or managing their chronic condition, through individual counseling sessions, telephonic or electronic contacts, office visits with physicians, and some home visits. By providing case management for patients and involving the patient's family, a Care Navigator focuses on patient education and compliance with the care plan, including medication adherence. The Care Navigator works closely with Medical Home/primary care practices and specialty practices for development of the care plan and case management, and is embedded in the physician offices. The Care Navigator works closely with hospitals, home care and other providers to coordinate transitions across the care continuum and arrange access to community resources needed by patients. The Care Navigator uses computer systems and tools for population management activities, to identify potential patients for case management, for access to patient information and for documentation of Care Navigation activities. The Care Navigator plays a key role in developing and implementing the programs. JOB DUTIES/RESPONSIBILITIES Duty 1: Using patient centric team based approach, acts as liaison to coordinate patient care and facilitate patient care pathway, among payers, physicians, physician offices, nursing, surgical department, therapy department, pharmacy, case managers, discharge planning, post-acute care, and other hospital departments as needed. Duty 2: Establishes regular communication and works on site in physician offices to accept referrals of patients to the Care Navigator program and to case manage the patient load. Serves as a clinical resource/consultant to physician practices to optimize communication and effective utilization of health care resources. Duty 3: Identifies and prioritizes patient caseload using designated patient identification process, daily admission and ER visit reports, the Medical Home registry, medication compliance profiles, physician and office staff referral, patient self-referral, and other means approved by the Medical Management Committee and BVHS. Duty 4: Coordinates care and addresses individual needs of patients who are assigned to caseload through the course of the designated episode, including direct patient support for the collection of functional outcomes and reporting. Duty 5: Utilizes nursing processes to assess and plan strategies for patient care with emphasis upon appropriate resource utilization, appropriate levels of care, quality and patient and family education. Develops and implements plans of care which address the specific diagnosis, age, gender, psycho-social and emotional needs of each patient, and which are culturally sensitive. Duty 6: Establishes and maintains communication/collaboration with the interdisciplinary team across the continuum of care (inpatient case management, home care, SNF care) and with the patient's primary and specialty providers regarding patient condition, orders, plan of care, anticipated needs, and progress. Duty 7: Evaluates patient access to needed services and coordinates access to the care continuum and community resources. Maintains active communication and collaboration with BVHS entities and community agencies and resources to assist patients and families to gain access to these services. Appropriately refers patients with physician approval to appropriate resources for education, services, and resolution of care issues of the patient. Duty 8: Counsels directly and often in person wiApply here: https://www.aplitrak.com/?adid=YmJn