RN Primary Care Navigator | Polson Primary Care Clinic

Primary Care NavigatorHelp us be the connection that keeps care moving forward!Our Mission: Quality, compassionate care for all.Our Vision: Reimagine health care through connection, service and innovation.Our Core Values: Be Kind | Trust and Be Trusted | Work Together | Strive for Excellence.Polson Primary Care, the position is vital for Transitional Care Management, Emergency Department follow-up, day-to-day coordination and clinic support, as well as Chronic Care Management services.Logan Health is looking for a resourceful and compassionate RN to join our team as a Primary Care Navigator!As an RN Primary Care Navigator, you will help patients—ranging from pediatrics to the elderly—connect with essential healthcare services. Your role will focus on chronic disease management, patient education, care coordination, emergency department follow-up, and clinic support. You will be a crucial liaison between patients, families, and healthcare teams, ensuring smooth transitions and continuity of care.This role will be located at our Polson, MT, Primary Care Clinic at 160 Heritage Way, Kalispell, MT.Key Responsibilities:Enroll patients in the CCM Program and educate them on program benefits.Outreach to patients that may need care navigation services.Provide patient education on chronic disease management, medication adherence, and treatment plans.Coordinate care across multiple settings such as primary care, specialty services, inpatient and outpatient settings.Facilitate timely scheduling of appointments, referrals, diagnostic testing, and proceduresAssist patients in accessing resources for housing, care assistance, and placement services.Engage with primary care and specialty providers to facilitate communication and optimize patient outcomes.Track patient progress and provide follow up as needed to ensure effective care management.What We're Looking For:Strong phone and in-person communication skillsSelf-starter, organized, and detail-oriented with excellent follow-up skills.Team player who collaborates well across disciplines and works independently when needed.Caring and compassionate demeanor with a positive attitude and commitment to patient-centered care.Experienced RN with history of managing chronic conditions is highly preferred.Why Join Us?No Weekends! No Holidays!Supportive & Collaborative Environment: Work with a dedicated team that values trust, teamwork, and excellence.Opportunities for Growth: Expand your skills in care coordination, chronic disease management, and patient advocacy.Competitive Compensation & Benefits: Affordable health benefits, generous matching 401(k), Fitness Center membership discount, Tuition Reimbursement Program, and employer paid life insurance!If you're an organized, self-driven professional who thrives in a collaborative environment and excels in phone-based patient support, we'd love to hear from you!Qualifications:Current Montana RN license or a multi state compact license with authorization to practice nursing within the state of Montana; required. Bachelor's Degree in Nursing preferred.RQI Provider (BLS) within 7 days of hire/transfer or before independent patient care, whichever comes first.Possess and maintain computer skills to include working knowledge of Word, Outlook, Excel, PowerPoint, Access and ability to learn other software as needed. Knowledge of electronic health records preferred.Must function with a high degree of autonomy, communication and interpersonal skill. Must understand the health care continuum and have the ability to solve complex problems.Demonstrated ability to work collaboratively with multidisciplinary medical home care teams. Knowledge of professional practice standards, regulatory requirements, and systems operations required.Nursing experience in a variety of care settings (Outpatient Clinic, SNF, Home Health, and Acute Care) preferred. Knowledge of Value-based payment models and the Medical Home care model preferred.Ability to evaluate clinical outcomes across a variety of primary care settings and familiarity with diabetes and lipid management, including dietary assessment preferred.Excellent organizational skills, detail-oriented, a self-starter, possess critical thinking skills and be able to set priorities and function as part of a team as well as independently.Commitment to working in a team environment and maintaining confidentiality as needed.Excellent verbal and written communication skills including the ability to communicate effectively with various audiences.Excellent interpersonal skills with the ability to manage sensitive and confidential situations with tact, professionalism, and diplomacy.Other Job Specific Duties:Assesses patient needs upon initial encounter and periodically throughout navigation. Matches unmet needs with appropriate services, referrals and support services, such as dietitians, providers, social work, pharmacy, and financial services. Acts as a liaison between the patients, families, caregivers and the providers to optimize patient outcomes.Identifies high risk patients who would benefit from chronic care management and works collaboratively with the primary care provider, patient, and family to develop an individualized patient-centered plan of care.Participates in coordination of the plan of care with the multidisciplinary team, promoting timely follow-up on treatment. Facilitates timely scheduling of appointments, referrals, diagnostic testing, and procedures to expedite the plan of care and to promote continuity and quality care.Utilizes appropriate assessment tools (e.g., PHQ2/9, mini cog, pain scale, etc.) to promote a consistent, holistic plan of care. Provides psychosocial support to and facilitates appropriate referrals for patients, families, and caregivers, especially during periods of high emotional stress and anxiety.Provides and reinforces education to patients, families, and caregivers about chronic disease process, discharge teaching/instructions, new diagnosis, and medications.Builds therapeutic and trusting relationships with patients, families, and caregivers through effective communication and listening skills. Utilizes motivational interviewing techniques to assist patients in meeting goals and managing chronic disease.Facilitates communication among members of the multidisciplinary primary care team to prevent fragmented or delayed care that could adversely affect patient outcomes.Supports a smooth transition of care for patients from one level of care to another. Provides acute care, skilled nursing facility, and emergency department (ED) follow up.Participates in the tracking of metrics and patient outcomes, in collaboration with administration, to document and evaluate outcomes of the navigation program. Focuses on prevention measures consistent with established guidelines and care process models and works toward continuously improving quality metrics and closing care gaps.Collaborates with the care navigation team to develop and improve workflows and protocols for primary care that ensure hospital, ED, and community resource follow-up.Exhibits effective communication with peers, members of the multidisciplinary healthcare team, and community organizations and resources.Works collaboratively with fellow members of the Care Navigation team, providers, and integrated multi-disciplinary team members.The above essential functions are representative of major duties of positions in this job classification. Specific duties and responsibilities may vary based upon departmental needs. Other duties may be assigned similar to the above consistent with knowledge, skills and abilities required for the job. Not all of the duties may be assigned to a position.Maintains regular and consistent attendance as scheduled by department leadership.Shift: Day Shift - 8 Hours (United States of America)Schedule: Full-time, 40 hours per week, 8-hour day shifts. Monday - Friday, no Holidays, no weekends.Logan Health operates 24 hours per day, seven days per week. Schedules are set to accommodate the requirements of the position and the needs of the organization and may be adjusted as needed.Notice of Pre-Employment Screening RequirementsIf you receive a job offer, please note all offers are contingent upon passing a pre-employment screening, which includes:Criminal background checkReference checksDrug ScreeningHealth and Immunizations ScreeningPhysical Demand Review/ScreeningEqual Opportunity EmployerLogan Health is an Equal Opportunity Employer (EOE/AA/M-F/Vet/Disability). We encourage all qualified individuals to apply for employment. We do not Logan Health