Care Navigator (RN)

The Role

Working within an interdisciplinary care team, the Care Navigator is responsible for proactively engaging patients identified as high-risk and implementing targeted interventions to address social needs and increase access to care. The Care Navigator will provide guidance and oversight of care coordination efforts to other members of the team, and handle clinical escalations as indicated.

This role requires an understanding of how socio-economic stressors can impact ability to engage in healthcare and subsequent health outcomes. Experience will ideally include prior work with patients with behavioral health diagnoses, as well as in navigating local community-based resources and benefit applications.

This role has a mobile presence, involving travel to patients’ homes, treatment facilities and community-based settings, and assigned clinics to facilitate and foster connections.

Major Duties and Responsibilities

• Conduct Transitions of Care Management for a subset of the patient population, including ER and hospital follow ups
• Provide triage guidance and supportive consultation to other team members, handling escalated complex cases
• Develop care plans leveraging 5Ms Geriatric best practice framework
• Develop a wholistic view of patient needs related to Social Determinants of Health
• Identify existing barriers to engagement with necessary resources and supports
• Provide education around maintenance of chronic health conditions, as well as available options for behavioral care and social support
• Serve as liaison between the patient and the direct care providers, assisting in navigating both internal and external systems
• Initiate care planning and subsequent action steps for high-risk members, coordinating with interdisciplinary team
• Supporting patients’ self-determination, motivate patients to meet the health goals they have identified
• Refer patient to necessary services and supportsThis field may include but is not limited to: assistance with transportation, food insecurity, navigation of and application for benefits including, Medicaid, HCBS, working to reduce costs associated with prescription medications, organizing schedules of follow up appointments, alleviating social isolation

• Lead Interdisciplinary Team Meetings when indicated
• Assess patient’s family system, and conduct family meetings with patient and family when needed
• Participate in creation and facilitation of team training content
• Conduct group psychoeducation and support groups within the Center
• Perform all other duties and responsibilities as required
• Participate in and lead interdisciplinary review of and coordination around complex patients
• Maintain patient confidentiality in accordance with HIPAA
• Document patient encounters in medical record system in a timely manner
• Follow general policies related to fire safety, infection control and attendance

Required Qualifications

• Registered Nurse (RN license)
• Minimum of 4 years of experience working in human services and navigating community-based resources

Preferred Qualifications

• Familiarity with state Medicaid guidelines and application processes preferred
• Experience working with patients with behavioral health conditions and substance use disorders preferred
• Prior experience conducting home visits and knowledge of field safety practices preferred

Job Type: Full-time

Benefits:

• 401(k)
• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible schedule
• Health insurance
• Life insurance
• Paid time off
• Parental leave
• Vision insurance

Medical specialties:

• Primary Care

Schedule:

• 8 hour shift
• Monday to Friday

Work setting:

• In-person

Ability to commute/relocate:

• Richmond, VA 23225: Reliably commute or planning to relocate before starting work (Required)

Experience:

• Human Services: 4 years (Required)

License/Certification:

• RN License (Required)

Work Location: In person

Salary : $67,700 - $85,800