Patient Care Navigator

Description

POSITION:             Patient Care Navigator

STATUS:                Non-exempt; Full time

REPORTS TO:       Director of Performance Improvement

SUPERVISES:        None

DEPARTMENT:      Performance Improvement

UNIT:                     Care Management Program (not Unit yet)

OFFICIAL DUTY STATION: hybrid/clinic location TBD

SUMMARY: 

The  Patient Care Navigator (PCN) performs essential functions of care coordination as part of the expanded Care Team and Care Management. The PNC is responsible for providing short-term services based on a care plan for the referred client/patients as related to utilization/ follow-up of external community resources and specialty referrals.  The PNC manages specified cases, coordinates health care benefits, provides education and facilitates our patients/members access to care in a timely and cost-effective manner. The PNC collaborates and communicates with patients/members, family/support persons, providers, to promote wellness and member empowerment, while ensuring access to appropriate services and maximizing member benefit.  The PNC serves as an active interdisciplinary team member, liaison with other departments and external health and social service providers. This position helps address patients and members social needs that may be identified during such screening workflow, ECM work, or Care Management service provided by RNs.

The PNC, as part of the Care Management Program, shall also assist in other care coordination programs as assigned by Director of Performance Improvement, including administration of (1) APHCV’s Remote Patient Monitoring (RPM) Program, where he/she will monitor and track distribution of RPM equipment, provide and/or facilitate patient education on the use and care of the RPM equipment, and provide overall implementation coordination of the RPM program; (2) Care coordination of AWV visits for Medicare or MediCal beneficiary including outreach and appointment scheduling and other programs as assigned.

Care Coordination provided byas PNC is an essential part of the clinic care team to support, guide and assist patients and families through the arrays of healthcare systems, acts as a communication liaison to understand the patients’ individual needs, preferences, and concerns, collaborates with the core care team (Provider and MA), extended care team (Big Care Team, Clinic Operations, other units) and external service providers, including community-based organizations to support a coordinated care for the Patient. 

The Care Management Program is currently in the Department of Performance Improvement. However, the Program might become a Unit and transferred to another Department in the near future.

APHCV expects all employees to respond and participate to emergency situation per emergency policies and procedures.

APHCV requires all staff to comply with Standards of Conduct and Compliance Program related policies and procedures. Such compliance is part of this position’s performance evaluation.

APHCV is a tobacco-free organization.

DUTIES AND RESPONSIBILITIES:

Care Navigation

1. Supports Care Team by:

i.   Connects patients to social support services including transportation, food resources, energy assistance programs, housing and others.

ii. Assist with connecting patients to specialty services including providing patients with referral information and authorization to assistance with scheduling and communication and other health literacy issues.

2. Ensure documentation in E.H.R. to maintain integrated information and communication with Care Team.

3. Participate in huddles as appropriate to ensure communication with Care Team.

4 .Conduct Health Assessment to develop more informed Health Action Plan to assess patients’ needs in the areas of physical health, mental health, SUD, community-based Long Term Services & Supports, oral health, palliative care, trauma-informed care, social supports, and housing (as appropriate for individuals experiencing homelessness).

5.Ensure that provision of Health Action Plan services and implementation of Health Action Plan are complete as they relate to care navigation and care coordination.

6. Use motivational interviewing, trauma-informed care, and harm-reduction practices to the care provided to patients and members.

Remote Patient Monitoring Program

7. Administer Remote Patient Monitoring program for APHCV’s Chronic Care Management Program.

8. Monitor, track and report on distribution of RPM equipment

9. Provide and/or facilitate patient education on the use and care of the RPM equipment.

Care Coordination for AWV

10. Conduct outreach and schedule AWV appointments for APHCV Medicare beneficiaries, both managed care and non managed care.

11. Coordinate referrals for Chronic Care Management services of Medicare beneficiaries.

QUALITY IMPROVEMENTS AND QUALITY ASSURANCE

12. Participate in various QI and QA activities as assigned.

OTHER DUTIES

13. Any other duties CEO and/or DPI might assign.

Qualifications

Experience

• Required
  • Associate’s or Bachelor’s degree
  • Additional years of qualifying work experience may be considered in lieu of degree
• Preferred
  • Previous experience providing case management and/or care coordination for vulnerable and/or underserved populations

Skills

• Required:
  • Comfortable working with diverse populations.
  • Exceptional ability to connect and engage with people.
  • Ability to engage members
  • Critical thinking skills & effective verbal and written communications skills to consult with members, physicians, and providers
  • Ability to use a personal computer and document care management activities.
• Preferred
  • Motivational interviewing,
  • Current knowledge of clinical standards of care and disease processes.
  • Knowledge of community resources in area of residence.
  • Familiarity with trauma-informed care and harm reduction practices
  • Fluency in both English and Spanish

HR Procedural requirements:

• Legal authorization to work in the United States
• A valid California Driver’s license with clean records and access to insured automobile
• Completion of APHCV Health Assessment Form
• Completion of DOJ background check

Salary : $22 - $25