Nurse Navigator - Bayview Physicians Group

Assists and provides support to high risk patients who require support to address barriers to improved care and their overall health outcomes and empower patients to become active participants in their own care. Assists with coordination of care between healthcare providers to ensure that patients receive the right care at the right place and the right time.

Work in collaboration with members of the patient’s care team and communicate effectively. Candidate must be able to thrive in a moderately paced, urgent need, complex, health care environment, where the Nurse Navigator works as a key, valued member of the multidisciplinary team.

Patients with moderate and high risk for poor outcomes / inefficient care require additional assistance to manage their chronic conditions. The nurse navigator will address any gaps in care that are identified, alongside the primary care physician and specialists to improve patient health outcomes, quality of life and improve the patient care experience. This is in addition to coordinating medical appointments; addressing patients’ barriers to medication regimen adherence, reminding patients of appointments, coordinating nonclinical services (such as transportation home health aide). Maintain appropriate documentation of patient contact, referrals made, and services provided. Must always be time-efficient, organized, professional and compliant with HIPAA rules and regulations.

Duties will include:

• Demonstrates proficient computer skills and is able to function within the electronic medical record as well as other computer software programs.
• Supports practice manager with the implementation of key processes of patient centered initiatives in the practice.
• Facilitates staff training and education on the tenets of patient centered care, chronic disease management and referral/order management.
• Empower the patient/ family to collaborate with the healthcare providers to create and maintain a patient-centered care plan. .
• Will work in collaboration with the primary care physician to notify the office of the patient's disposition and any available clinical details.
• Reviews documentation provided from insurance carrier, medical record, care plan, records from hospital or other referral sources to determine patient needs for navigation services and discuss a patient specific plan of action.
• Facilitate the scheduling of follow up appointments during transitions of care.
• Will contact high-risk patients after the office follow up visit and review their care plan and follow up visit instructions through teach-back techniques. Help facilitate any orders for tests/ procedures / referrals or subsequent follow up appointments.
• Answers general questions about tests, procedures, getting to offices, labs, hospitals. Help patients to formulate questions to ask their healthcare provider and to be empowered to participate in shared decision making.
• Provides referrals to other local agencies, as appropriate, for services such as transportation etc.
• Work closely with the PCP’s office staff and attributed patients to close gaps in care.
• Documents all client interactions in electronic database with accurate notes indicating interactions with patients, specialists, care providers and hospital staff ancillary service providers.
• Works collaboratively as a team with other Nurse Navigators and office staff to ensure that each patient receives comprehensive services.
• Other related duties or special projects related to quality activities or initiatives as assigned by supervisor.
• Education: Registered Nurse or Licensed Practical Nurse
• Experience: At least 3 years minimum experience in an outpatient healthcare setting

Job Type: Full-time

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