Clinical Care Navigator

Job Description

Job Description

POSITION SUMMARY

As a Clinical Care Navigator, you will assist in delivering care to patients with dementia under the (Guiding an Improved Dementia Experience) GUIDE model. You will build strong, collaborative relationships with internal teams as well as external partners to ensure patients receive appropriate and high-quality care. Assessment, care planning, coordination of care and resources, and transitional care management are foundational to the position. This position will include in-home assessments of beneficiaries along with frequent telephonic / video visits to provide support to patients and their caregivers.

QUALIFICATIONS

Education : High school diploma or GED; satisfactory completion of a Medical Assistant, Certified Nursing Assistant, or Licensed Practical Nurse training and competency evaluation program that complies with Arkansas Department of Health guidelines also required.

Experience : A minimum of two (2) years of healthcare experience working with patients. Preference will be given to those with experience working with a geriatric or dementia population.

Licensure : Certified Nursing Assistant (CNA)

Additional Requirements : Must be eligible for a Letter of Determination and successfully complete a skills evaluation test. A valid Arkansas driver’s license, car insurance, and car are also required ( Home Care ).

PRIMARY RESPONSIBILITIES

• Conducting comprehensive assessments that include clinical, behavioral, psychosocial, and advance care planning domains.
• Reviewing current health needs, identifying goals, and developing individualized care plans.
• Develop and maintain resource files and network with other service providers to assist clients.
• Knowledge of the rules and regulations of the GUIDE Program.
• Regularly review the GUIDE program website and make sure all information is up to date and correct in regard to beneficiaries, partners and providers.
• Submit thorough and timely documentation and within the same day as service delivery.
• Assist patients and families by educating on available resources and services.
• Facilitating support groups for patients and their caregivers.
• Collaborating with primary care clinicians to ensure high quality team-based care.
• Use utilization management tools to facilitate appropriate transitional care management.
• Collaborate with hospitals, rehabs, and SNFs to manage patient’s inpatient stay and desired discharge plan.
• Track needed data and complete benchmarking tool.
• Communicate effectively with internal and external stakeholders.
• Help reduce unnecessary visits to the emergency departments as to acute settings with the goal of reducing utilization and unnecessary costs.
• Work to increase coordination of care for a vastly complex geriatric population.
• Be proficient in community resources.
• Constantly review the Remote Patient Monitoring (RPM) software and alert clinicians when readings are outside set parameters.
• Work with clinicians in the placement and educating patients on the use of the RPM equipment.
• Work with billing to ensure all appropriate RPM and GUIDE codes are billed in a timely manner.
• Proactively engage with providers to identify high risk patients.
• Ensures compliance with all applicable state and federal laws, regulatory standards, contracts and organizational policies and procedures, etc.
• Accepts direction and follows instructions from supervisor; seeks additional information as needed; works with minimal supervision.
• Completes special projects as assigned by Manager, Director or CMO.
• Adheres to all organizational and departmental policies and procedures.
• Continually meets organizational standards for attendance and punctuality; notifies supervisor in a timely manner when employee will be absent or late for work.
• Attends all required meetings and in services; seeks opportunities for additional professional development activities as appropriate.
• Performs other duties as assigned.

COMPETENCIES, KNOWLEDGE, SKILLS, AND ABILITIES

THIS SECTION DESCRIBES WHAT KNOWLEDGE, SKILLS AND ABILITIES AN EMPLOYEE IN THIS POSITION SHOULD CURRENTLY POSSESS. THIS LIST MAY NOT BE COMPLETE FOR ALL KNOWLEDGE, SKILLS AND ABILITIES REQUIRED FOR THIS POSITION .

Performs the above listed functions while regularly working with confidential and / or proprietary Arkansas Hospice and patient information, including but not limited to patient medical records, current or former employee information, Arkansas Hospice records, and other information that the employee regularly uses to perform job functions.

This position is designated as a safety sensitive position because it requires the regular handling of confidential and / or proprietary Arkansas Hospice and patient information, performing life-threatening procedures, monitoring and / or operating equipment used to perform medical procedures, and / or working with controlled substances and / or medicine. Any lapse of attention could have a significant impact on Arkansas Hospice and / or its patients, and could result in injury, illness, or death. For the safety and health of yourself and others, you must be able to work in a constant state of alertness and concentrate for long periods of time while performing life-threatening procedures, monitoring and / or operating equipment used to perform medical procedures, and / or working with controlled substances and / or medicine.