Care Navigator (MSW)

Description

Our Organization
Humana’s Primary Care Organization is one of the largest and fastest growing value-based care, senior-focused primary care providers in the country, operating over 270 centers serving over 250,000 patients. As a payor-agnostic, wholly owned subsidiary of Humana, our centers put the unique needs of seniors at the center of everything we do. Our Clinics offer a team-based care model supporting patients’ physical, emotional, and social wellbeing.

At CenterWell Senior Primary Care, we want to help those in the communities we serve, including our associates, lead their best lives. We support our associates in becoming happier, healthier, and more productive in their professional and personal lives. We promote lifelong well-being by giving our associates fresh perspective, new insights, and exciting opportunities to grow their careers. Our culture is focused on teamwork and providing a positive and welcoming environment for all.

This is a unique opportunity to directly connect with patients on the barriers most affecting their ability to engage in the care they need, and subsequently work to find solutions that positively impact their quality of life. We are looking for individuals who are:
• Dedicated to serving at risk populations most in need of additional supports
• Creative problem solvers
• Enthusiastic about working in a fast paced and developing market

Responsibilities

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 supports
  • This 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

• Master’s Degree in Social Work
• Minimum of 4 years of experience working in human services and navigating community-based resources
• Bilingual in English/Spanish with the ability to speak, read and write in both languages without limitations and assistance (if reside in X, Y and Z markets)

Preferred Qualifications

• LMSW Licensure if applicant holds an MSW
• 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

Skills/Abilities/Competencies Required

• Advanced clinical acumen
• Ability to multi-task in a fast-paced work environment
• Flexibility to fluidly transition and adjust in an evolving role
• Excellent organizational skills
• Advanced oral and written communication skills
• Strong interpersonal and relationship building skills
• Compassion and desire to advocate for patient needs
• Critical thinking and problem-solving capabilities

Working Conditions 

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

Workstyle: Combination in clinic and field, local travel to meet with patients

Location: Must reside in Indianapolis IN Metro

Hours: Must be able to work a 40 hour work week, Monday through Friday 8:00 AM to 5:00 PM, over-time may be requested to meet business needs.

               

Tuberculosis (TB) screening: This role is considered member facing and is part of Humana’s Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.

Driver's License, Reliable Transportation, Insurance This role is part of Humana's Driver safety program and therefore requires an individual to have:

• a valid state driver's license,
• proof of personal vehicle liability insurance with at least 100/300/100 limits,
• and a reliable vehicle.

Benefits

Health benefits effective day 1

Paid time off, holidays, volunteer time and jury duty pay

Recognition pay

401(k) retirement savings plan with employer match

Tuition assistance

Scholarships for eligible dependents

Scheduled Weekly Hours

40