Care Navigator

About Our Company: We’re a physician‑led, patient‑centric network committed to simplifying health care and bringing a more connected kind of care. Our primary, multispecialty, and urgent care providers serve millions of patients in traditional practices, patients' homes and virtually through VillageMD and our operating companies Village Medical, Village Medical at Home, Summit Health, CityMD, and Starling Physicians. Job Description The Care Navigator directly supports and promotes the care transitions and social support needs of patients across the continuum of care. S/he also supports quality improvement initiatives through targeted outreach to patients who are not meeting clinical goals. This position collaborates with providers, RN Care Managers, Social Workers and others to facilitate seamless transitions of care, social support interventions, and patient outreach and engagement to close care gaps, with the goal of assuring superior patient experience and quality outcomes. Responsibilities Essential Job Functions: Establishes and maintains external relationships with hospitals, rehabilitation facilities and other post‑acute care facilities by: (1) promoting ongoing collaboration and regular communications with facilities and providers; (2) conducting and documenting routine/weekly outreach calls to all facilities to gather critical clinical information about admitted patients; and (3) demonstrating effective relationship‑building skills. Works collaboratively with both internal and external entities to facilitate seamless transitions across the continuum of care by adhering to departmental administrative TOC workflow standards. At time of patient discharge, initiates and completes the TOC process on behalf of client’s providers and ensures a seamless handoff of information to RN Care Managers and other interdisciplinary team members for further follow‑up post‑discharge. Manages low risk patients discharged from an inpatient facility by providing outreach to the patient and adhering to an established care pathway and algorithm designed for the outreach process for low risk patients. Collaborates with the Social Support team and manages the information, referral and assistance inquiries received; ensures that outreach to patient/family member/caregiver is completed in a timely and efficient manner. Maintains the Social Services Directory. Supports the Hospitalist Teams in creation of and distribution of the daily inpatient hospitalist census in a timely and efficient manner ensuring all relevant patient information is included in the daily hospitalist census including attribution status. Tracks “Avoidable Admissions” by receiving email from the Hospitalist team identifying a patient that was treated in the ER but not admitted to hospital. Follows established workflow of patient case being created and PCP office being notified of need for outreach to avoid recurrent ED visit/hospitalization. Provides care coordination and social support services as needed. Identifies patients not meeting clinical goals or important quality metrics and arranges follow‑up by protocol, as appropriate. Uses registry tools to identify and track patients. Conducts follow‑up activities with patients who have not kept important appointments or completed needed diagnostic testing. Identifies patients and families who would benefit from additional care management/social work support and makes appropriate referrals. Reviews and updates medication list and accurately documents known allergies in the Electronic Health Record (EHR). Demonstrates an understanding of prescription control and prescription refill procedures. Records patient information accurately to support population health initiatives. Updates data worksheets with outcomes following patient contact and recommendation of needed services and appointments. Facilitates and arranges new patient and follow‑up services per treatment protocol, as appropriate. General Job Functions: Collects, tracks, trends and reports clinical data, as needed, for all Transitions of Care Program patients, Low Risk Care Management patients, Social Support Program patients, patients discharged from the ED, and patients requiring outreach for closing care gaps. Maintains information flow and communications with non‑SMG collaborating providers to ensure efficient patient care. Demonstrates appropriate and timely use of the EMR. Attends all pertinent departmental meetings and trainings that involve the Care Management team, Social Support Program, hospitalist or extensivist workflows. Assists with special projects as assigned and completes them within the required timelines. Effectively communicates problems, concerns or issues to the Supervisor and/or Manager appropriately and promptly. Qualifications Bachelor’s Degree preferred but not required. Certified Medical Assistant, Licensed Practice Nurse in the State of Oregon, preferred or other relevant clinical experience considered. 2–4 years of relevant work experience in the health care field is preferred. Valid Driver’s License. Must be proficient in computer skills. Must be proficient in Microsoft Office, Excel, Word and PowerPoint. Physical Job Requirements Physical mobility, which includes movement from place to place on the job, taking distance and speed into account. Physical agility, which includes ability to maneuver body while in place. Dexterity of hands and fingers. Endurance (e.g., continuous typing, prolonged standing/bending, walking). Environmental Risks Extreme temperature. Confined spaces. Total Rewards Participation in VillageMD’s benefit platform includes Medical, Dental, Life, Disability, Vision, FSA coverages and a 401(k) savings plan. Equal Opportunity Employer Our Company provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to, and does not discriminate on the basis of, race, color, religion, creed, gender/sex, sexual orientation, gender identity and expression (including transgender status), national origin, ancestry, citizenship status, age, disability, genetic information, marital status, pregnancy, military status, veteran status, or any other characteristic protected by applicable federal, state, and local laws. #J-18808-Ljbffr