RN, Chronic Care Navigator (NonExempt)

RN, Chronic Care Navigator (NonExempt)

The Chronic Care Nurse Navigator plays a pivotal role in coordinating comprehensive care for patients with chronic conditions. This individual will serve as a central point of contact, guiding patients and their families through the healthcare system, ensuring timely access to services, and promoting adherence to treatment plans. The Nurse Navigator will also educate patients on self-management strategies and connect them with community resources.

Responsibilities:

• Patient Advocacy and Education: Act as a patient advocate, ensuring their needs and preferences are addressed throughout their care journey. Provide education to patients and families regarding their chronic conditions, treatment plans, medication management, and lifestyle modifications. Empower patients to participate in their care decisions and develop self-management skills actively.
• Care Coordination and Navigation: Assess patient needs and develop individualized care plans in collaboration with the healthcare team including primary care providers, clinic patient navigator, case management team, and clinic office staff. Coordinate appointments, diagnostic tests, and specialist referrals. Facilitate communication between patients, families, and all members of the healthcare team. Identify and address barriers to care, such as transportation, financial constraints, or lack of social support, and work in conjunction with the patient navigator/navigation team. Monitor patient progress and make adjustments to care plans as needed. Oversight of the clinic patient navigator to ensure that patients needing primary care and specialty care are be captured and referred as needed.
• Resource Management: Connect patients with relevant community resources, support groups, and educational materials. Maintain an up-to-date knowledge of available resources and services.
• Documentation and Communication: Maintain accurate and thorough documentation in clinic and hospital electronic medical record of patient encounters, care plans, and outcomes. Communicate effectively with providers, patients, and families, ensuring clear understanding of information. Participate in interdisciplinary team meetings to discuss patient care.
• Quality Improvement: Contribute to the development and implementation of quality improvement initiatives related to chronic care management. Identify trends and areas for improvement in patient care processes. Monitors billing/compliance/reimbursement for areas of improvement.

Qualifications:

• Education: Associates or better in Nursing required. Bachelors or better in Nursing preferred. Masters or better in Nursing preferred.
• Licensure/Certification: Current, unencumbered Registered Nurse (RN) license in Texas. Certification in Chronic Care Management or a related specialty (e.g., Certified Case Manager, Certified Diabetes Educator) preferred.
• Experience: Minimum of 5 years of clinical experience in a chronic care setting. Experience in patient education, case management, or care coordination strongly preferred.
• Skills: Excellent communication, interpersonal, and organizational skills. Strong critical thinking and problem-solving abilities. Proficiency in electronic health records (EHR) systems. Ability to work independently and as part of a multidisciplinary team. Compassionate and empathetic approach to patient care.

Working Conditions:

• This position primarily operates in an office or clinical setting.
• Occasional travel to community events.
• May be exposed to confidential patient information.

Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.