Nurse Navigator

Job Description

Job Description

Definition:

 

Under the direct supervision of the Chief Medical Officer, the incumbent provides oversight and manages the Care Coordinator Program. This is a highly visible position, and the incumbent is expected to “take initiative” and set high standards of professional conduct and work performance.

 

Team Philosophy Statement :

 

The Henrietta Johnson Medical Center provides affordable access to integrated and coordinated family practice, women’s health, dental and behavioral health care services to the entire family under one roof. We operate with a team of caring, competent, and productive providers and staff who focus on quality, compassionate, and coordinated care in order to provide outstanding service to patients and families. Our staff place a high value on teamwork. They must accept changing duties, be multi-skilled, and perform a variety of tasks in the care of our patients. Each member of the team is dedicated to continuous learning, and contributes toward our goal of providing outstanding health care services to our patients.

 

Major Responsibilities:

 

• Promote timely access to appropriate care.
• Increase utilization of preventative care.
• Reduce emergency room utilization and hospital readmissions.
• Increase comprehension through culturally and linguistically appropriate education.
• Create and promote adherence to a care plan, developed in coordination with the patient and primary care provider.
• Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and Annual Wellness Visits.
• Increase patients’ ability for self-management and shared decision-making.
• Provide medication reconciliation.
• Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction.
• Other duties as assigned.

Performance Criteria

 

• Oversees the cultivation and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care, Chronic disease management, and Annual Wellness Visits.
• Manages the identification of “high-risk” patients (the chronically ill and those with special health care needs), and add these to the patient registry (or flag in EHR).
• Administers feedback for the improvement of the Care Coordination Program, manages patient transactions in care and Annual Wellness Visits.