Care Navigator

## Care Navigator Apply locations:
Bend, ORtime type:
Full time posted on:
Posted Yesterday job requisition :
R52420#
** About Our Company
** We’re a physician-led, patient-centric network committed to simplifying health care and bringing a more connected kind of care.

Our primary, multispecialty, and urgent care providers serve millions of patients in traditional practices, patients' homes and virtually through VillageMD and our operating companies Village Medical, Village Medical at Home, Summit Health, CityMD, and Starling Physicians.

When you join our team, you become part of a compassionate community of people who work hard every day to make health care better for all. We are innovating value-based care and leveraging integrated applications, population insights and staffing expertise to ensure all patients have access to high-quality, connected care services that provide better outcomes at a reduced total cost of care.
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* Please Note:

** We will only contact candidates regarding your applications from one of the following domains: , , , , , , or  
** Job Description
** The
** Care Navigator
** directly supports and promotes the care transitions and social support needs of patients across the continuum of care.
S/he also supports quality improvement initiatives through targeted outreach to patients who are not meeting clinical goals.
This position collaborates with providers, RN Care Managers, Social Workers and others to facilitate seamless transitions of care, social support interventions, and patient outreach and engagement to close care gaps, with the goal of assuring superior patient experience and quality outcomes.  The Care Navigator networks internally with SHM clients and externally to all care settings to obtain needed clinical information, engage and educate patients, identify risk factors for referrals, and perform an integral role in clinical data collection, tracking, trending and reporting on all outcomes.
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* Essential Job functions:

*** Establishes and maintains external relationships with hospitals, rehabilitation facilities and other post-acute care facilities by: (1) Promoting ongoing collaboration and regular communications with facilities and providers; (2) Conducting & documenting routine/weekly outreach calls to all facilities to gather critical clinical information about admitted patients; and (3) Demonstrating effective relationship-building skills
* Works collaboratively with both internal and external entities to facilitate seamless transitions across the continuum of care by adhering to departmental administrative TOC workflow standards.
* At time of patient discharge, initiates and completes the TOC process on behalf of client’s providers and ensures a seamless handoff of information to RN Care Managers and other interdisciplinary team members for further follow-up post discharge
* Manages low risk patients discharged from an inpatient facility by providing outreach to the patient and adhering to an established care pathway and algorithm designed for the outreach process for low risk patients.
* Collaborates with Social Support team and manages the Information, Referral and Assistance inquiries received; ensures that outreach to patient/family member/caregiver is completed in a timely and efficient manner.
Maintains the Social Services Directory.
* Supports the Hospitalist Teams in creation of and distribution of the daily inpatient hospitalist census in a timely and efficient manner ensuring all relevant patient information is included in the daily hospitalist census including attribution status.
* Tracks “Avoidable Admissions” by receiving email from Hospitalist team identifying a patient that was treated in ER but not admitted to hospital.  Follows established workflow of patient case being created and PCP office being notified of need for outreach to avoid recurrent ED visit/hospitalization.  Provide care coordination and social support services as needed.
* Identifies patients not meeting clinical goals or important quality metrics and arranges follow-up by protocol, as appropriate.  Uses registry tools to identify and track patients.  Conducts follow-up activities with…