LPN/LVN - Nurse Navigator

Responsibilities

Job Summary: The ACO LVN Navigator is a licensed clinical LVN who functions as a liaison between the ACO, the patient and the multidisciplinary healthcare team to assist in developing an optimal plan of care for transitioning Medicare patients, primarily those currently utilizing post-acute care services. The ACO Nurse Navigator assesses needs and coordinates resources within and outside the ACO (as approved by the ACO Director) to promote optimal health benefits and outcomes (both clinical and financial). The ACO LVN Navigator will provide onsite review at the local primary care practices and conduct patient home assessments as needed, as well as establish rapport with primary care providers, office staff, patients, and their families to expedite timely transitions of care and appropriate utilization of post-acute care services.

This position requires a high frequency of contact with the very high risk ACO patient and their care givers for education of health promotion and self-care skills as well as facilitating compliance with the required quality measures for all ACO patients. An ACO LVN Navigator will also ensure the communication of a patient's treatment plan and general status to all care givers during all transitions of care.

Qualifications

Job Duties/Responsibilities:

• Collaborates with physicians, post-acute facility providers, patients and deemed patient representatives to identify patient needs/resources.
• Ability to earn and maintain trust of patients, patient representatives, physicians and health care providers.
• Identifies needs of the patient and patient representatives and ensures sensitivity to any special needs of the patient.
• Identifies high-risk patients and coordinates resources to conserve.
• Facilitates problem solving and decision-making by providing guidance, knowledge of PAC utilization requirements, wellness resources, and supportive services and options to the patient, patient representative and health care providers.
• Timely documented communication and education with physician, patients and patient representatives regarding opportunities for modification of patient health risk factors.
• Participates in care conferences to enhance communication and promote continuity of care.
• Works closely with the ACO staff as well as contracted vendors and support staff to facilitate timely transitions of care.
• Researches service resources in the community and elsewhere to meet patient needs consistent with plan benefits.
• Prepares accurate and timely required department reports related to utilization

Requirements:

• Graduation from an accredited LVN certification program.
• Licensed by the State of Texas as an LVN.
• Minimum of two years' experience in post-acute care preferred.
• Recent (within past 3 years) working knowledge of Interqual criteria and Milliman Care Guidelines preferred.
• Ability to effectively communicate in English, both verbally and in writing.
• Bilingual Spanish preferred.
• Ability to document in different electronic health records as well as utilize Microsoft Products