Care Navigator

Job purpose

Care Navigators are responsible for the care management of patients in the primary care practice setting. Performs Provider-led Chronic Care Management for all patients with needs. Manage care planning for all complex chronic conditions, chronic, moderate, or episodic cases utilizing ambulatory care management processes.

This position performs comprehensive assessments, telehealth assessments and follow-up, face to face interventions, assessments and follow-up, and coordination of care including patient outreach, patient progress monitoring, and community and social services outreach. Scope of services also include a primary focus on assessments, follow-up, patient outreach, progress monitoring and managing care planning for High Utilizer/High Risk patient population. This is an interdisciplinary position that provides team-based care collaboration with both Behavioral Health and Chronic Disease teams. The scope of services may also include performing tasks related to value-based care and various initiatives.

· Candidate would be willing to provide in-person Care Management services covering multiple Alliance Health locations in Macomb County.

· This position will have (1) day designated for: Remote/Work-from-home.

Duties and responsibilities

Care Navigator collaborates with providers, care team members, and external community and social services resources to develop and monitor the patient’s daily living activities. Care Navigator monitors and follows up with patient progress towards care plan goals. Care Navigator creates a patient centered care plan, ensures barriers to health care are addressed, and facilitates the proper resources to address the needs of the patient. Identifies Social Determinants of Health along with identifies the targeted high-risk population within the practice site based on PCP referral, risk stratification, and patient lists. Care Navigator performs these essential duties as defined below:

• Assess patients with standardized and evidence-based tools telephonically as well as face to face, to develop a plan of care that complements the PCP’s plan of care and that addresses physical, educational, and psychosocial needs for the patient/family.
• Partners with the patient’s specialists, family, and other support systems such as neighbors, friends, community and social services resources to ensure stability.
• Provide self-management, self-care and education support to patients with a focus on healthy behavior changes to manage complex chronic conditions and chronic conditions. Utilize evidenced based interventions, motivational interviewing, or an empowerment approach with patients.
• Participate in community education and outreach activities such as health fairs or support groups.
• Provide resource support, education and care coordination during transitions between health care settings.
• Timely and consistent documentation in EMR.
• Identify practice-level population health goals and track how the practice is doing in relation to those goals. Track patient gaps in care and quality initiatives.
• Participate in continuing education and learning activities to advance skill set.
• Follows scope of practice guidelines, standards of profession, and all confidentiality/HIPPA/privacy laws.
• Other Duties as assigned.

Qualifications

These are the qualifications that are necessary for someone to be considered for the position.

Qualifications include:

• Licensed Masters in Social Work (LMSW) with at least 3 years of experience in healthcare, primary/ambulatory care, home health care, skilled nursing facility, or hospital.
• Experience with care management processes including care planning and assessing safety issues.
• Ability to provide outreach, disease management and/or self-management services to patients and families.
• Knowledge of quality metrics for chronic conditions and preventive services.
• Ability to communicate with patients, primary care physicians and the care team.
• Strong assessment, triage, diagnostic and therapeutic skills

Working conditions

The employee may occasionally have loud noise (patients, staff conversation), in the office but rarely will have any physical exertion or temperature changes.

Physical requirements

The employee will be required to listen to patients and communicate with them through listening and speaking with patients. The employee will frequently stand, walk, sit, handle papers (grip, feel and moving) throughout the day. They will rarely be required to lift, push, pull or move anything physically.

Direct reports

None. This person may be Team Lead and lead other employees through the program processes, workflows, and direction but does not supervise staff.

Job Type: Full-time

Pay: $67,000.00 - $74,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Day shift

Ability to Commute:

• Macomb County, MI (Preferred)

Ability to Relocate:

• Macomb County, MI: Relocate before starting work (Required)

Willingness to travel:

• 25% (Preferred)

Work Location: In person

Salary : $67,000 - $74,000